The tumor is out, and the hole is bigger than you’d expect.
A cancer the size of a fingernail gets cut out with healthy tissue around it in every direction, and what’s left can change how a person talks for good. When it reaches the jaw, surgeons rebuild it from the fibula, the thin bone in the lower leg. During my surgical residency, I was at the table for dozens of these operations. Most of those patients smoked.
Years later, I put a nicotine pouch under my own lip to see if it would sharpen my focus. Fifteen minutes later, I was in the bathroom.
You know cigarettes kill. What changed is where the nicotine went: into vapes, into pouches, into the office fridge. My verdict: for a smoker, a vape is the best exit there is. For everyone else, nicotine costs more than it gives.
Doctors know. Plenty still smoke.
A maxillofacial ward is a weird mix. Babies with cleft lips. Children whose skulls grew the wrong shape. Kids and adults after accidents. People having a jaw moved back or a nose reshaped. And the cancer patients, most of them smokers, many of them drinkers. We had a name for the pattern we kept seeing: the deadly triad. Smoking, drinking, and a mouth nobody looked after.
None of those patients thought smoking was good for them. Neither do the doctors who smoke, and there are plenty of them. Plenty drink, too. Medical training shows you exactly where risk ends up, and it still doesn’t stop people. Knowing has never been the hard part.
I call this information loses to incentives. A cigarette pays out within minutes: relief, a break, a reason to step outside, a few minutes with the people in the smoking corner. The bill comes 20 or 30 years later, and rarely announces itself. You know the same pattern from work. The deadline with a meeting attached beats the health cost with no deadline.
Nicotine is made for this trade. It’s legal, it’s fast, and the payoff is immediate. Long days, late flights, a deck due first thing in the morning: that’s exactly when a quick lift looks reasonable. It’s also why nicotine moved so easily from the cigarette into new forms.
In some offices it now comes free. According to Fortune, a Palantir spokesperson told the Wall Street Journal that the company stocks nicotine pouches for employees and guests over 21 [1]. When the employer pays for the habit, the short-term reward gets even harder to argue with.
What follows is the version I’d give a friend: the few numbers that matter. The rest is in the references.
Smoking plus drinking: 14 times the odds
Smoke damages the DNA in the cells lining your mouth, the first tissue it touches. Over years of heavy smoking, the odds rise that one damaged cell stops obeying the signal to stop dividing. That’s how a tumor starts.
Alcohol multiplies the damage. A pooled analysis of 17 studies with more than 11,000 head and neck cancer patients compared people by both habits [2]. More than a pack a day plus three or more drinks a day came to about 14 times the odds of these cancers, compared with people who did neither. Heavy smoking alone came to about 4 times, heavy drinking alone about 2. Together, the effect was bigger than the two multiplied.
If you only change one of the two, change the cigarettes.
Quit before 40, and most of the extra risk is gone
In data from 1.48 million adults in the US, the UK, Canada and Norway, quitting before 40 was linked to avoiding about 90% of the extra risk of dying early that smoking adds [3]. Quitting in your 40s still avoided most of it. The benefit showed up within three years.
The mouth recovers too. For mouth and throat cancer, people who had quit for a few years had about 30% lower odds than people who kept smoking. After 20 years or more, their odds were close to those of people who never smoked [4].
If you smoke, nothing else I will ever write in this newsletter comes close to the value of stopping.
Young adults vape four times more than they smoke
About 1 in 10 US adults smoked in 2024. Among 18- to 24-year-olds, 14.8% vaped and only 3.4% smoked [5]. The cigarette is shrinking, but the nicotine hasn’t gone anywhere.
Among US middle and high school students in 2025, about 1 in 20 had vaped in the past month, and about 9 in 10 used flavored products, mostly fruit, candy, and mint [6]. Youth vaping has come down since 2022, but it’s still the most common way teenagers use nicotine. Pouches are second.
I think taste explains a lot of this. A cigarette is harsh, and it smells. For a 15-year-old, that harshness used to be a barrier. A vape that tastes like mango takes the barrier away, and it leaves far less smell on their clothes for a parent to notice.
That matters more at 15 than at 45. The US Surgeon General concluded that nicotine during adolescence can cause addiction and can harm the developing brain [7].
For a smoker, a vape is the best exit
This sounds wild coming from me, but the evidence is on the vape’s side, and I’ll say so plainly. Across 11 trials, about 4 more people in every 100 quit smoking with a vape than with patches or gum, and Cochrane rates that evidence as high certainty [8]. In one large UK trial, 18 in 100 were off cigarettes a year later with a vape, against 10 in 100 with patches or gum [9].
Two catches, though. The goal has to be zero cigarettes. In a large US study, people who both smoked and vaped had the highest exposure to toxic chemicals of any group [10]. And the vape can become a habit of its own: in that UK trial, 8 in 10 people who quit with a vape were still vaping a year later [9]. For a smoker, that’s a good trade. It’s still a habit. My advice: once the cigarettes are gone, plan your way off the vape too, with your doctor if you need help.
Heated tobacco devices like IQOS are the other exit the tobacco industry sells. In the trials Cochrane reviewed, users took in fewer toxic chemicals than smokers but more than people who quit (not surprising), and every one of those trials was funded by tobacco companies [11].
For someone who has never smoked, none of this applies. Vapes have been common only since the 2010s. Nobody knows yet what 30 years of vaping does to a pair of lungs.
The pouch I tried once
In January I wrote here about a tin of nicotine pouches I’d bought in Sweden, and the question behind it: could nicotine sharpen my focus, maybe even help with my ADHD?
I did try. One of my flaws is believing that more is always better, and I think I used a pouch that was too strong. I don’t remember the dose. I remember what happened 10 or 15 minutes after I put it under my lip. I was sweating heavily. I was agitated, and my stomach turned. I ended up in the bathroom, and that was the end of the experiment. I never tried again.
Heavy sweating, agitation, and nausea are the textbook signs of too much nicotine. Mine was a textbook case.
The case for nicotine as a focus tool is real, as far as it goes. A review of 41 lab studies found small to moderate improvements in attention, reaction time, and short-term memory, in non-smokers too [12]. Those were short lab tests. Nobody measured whether anyone did better work or made better decisions. That’s the mechanism trap: an effect you can measure in a lab, and no data on the outcome you care about.
The dose problem is real too. When German researchers tested 44 pouches from 20 manufacturers, bought online in Europe, the nicotine inside ranged from under 2 mg to 47.5 mg per pouch. Two out of three products had no clear nicotine label [13].
ZYN’s new claim has a comparison in the fine print
On 30 June 2026, FDA authorized 20 ZYN products to carry this claim: “Using ZYN instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” [14]
The strongest case for it: if you smoke, it’s almost certainly true, and the FDA reviewed the company’s evidence before allowing it. That’s a real win for every smoker who switches.
The gap sits in three words: instead of cigarettes. The claim compares ZYN with smoking. It says nothing about ZYN against no nicotine at all, and the FDA’s own announcement repeats that there is no safe tobacco product [14]. The order covers the 3- and 6-mg pouches, not the stronger ZYN Ultra. It runs for five years, and the FDA can withdraw it if use among young people rises significantly.
My verdict on the claim: Keep, if you smoke. Cut, if you don’t. You’re the wrong population in that case.
My take on the matter:
Quitting cigarettes, at any age: Strong yes.
Switching completely from cigarettes to a vape: Yes, for smokers. Then try getting off vaping.
Smoking and vaping at the same time: Cut. You’re heading in the wrong direction and could be adding even more health risks.
Heated tobacco as the safer cigarette: Situational yes, for smokers who won’t quit any other way. Lower exposure to cancer-causing chemicals than smoking, but the research is industry-funded.
A nicotine pouch for focus, if you don’t use nicotine: Don’t. You’d be betting on a mechanism, not a proven outcome.
Any nicotine for a teenager: No. If focus is a challenge, work on the root causes instead.
This is load versus capacity at its plainest. Your job adds load. Capacity is what lets you carry it, and at 70 it’s what lets you think clearly, eat what you like, and talk without effort. Tobacco takes from all of it. That’s the Capacity pillar of my Upward ARC framework, and I watched it go, one patient’s mouth at a time.
Try this today
If you use nicotine in any form, write down every use for one week, then decide based on the number in front of you. If you smoke, book a doctor’s appointment about quitting that same week.
Ask your kids what their friends use before you ask what they use. Ask about flavors.
Any mouth ulcer that hasn’t healed within 3 weeks, and any red or white patch or new lump, gets checked by a dentist or doctor, especially if you smoke or drink [15].
Everything we rebuilt at that table came down to two ordinary things: eating and talking. Biting into a sandwich. Getting through a phone call without anyone asking you to repeat yourself. Most people only notice them when they’re gone.
If you quit smoking successfully, what finally did it? Press reply and tell me. I read every one, and I’m listening. If you’re still smoking, let this be the week you book that appointment.
Stay healthy.
Andre
PS: If someone you love still smokes, send them the section on quitting before 40. Skip the lecture. This is how this newsletter grows, and it’s the only way I want it to.
PPS: If a friend sent you this, you can get Under Load, my Sunday edition, here:
https://www.andreheeg.com
References
[1] Gioino, C. (2026, March 4). Palantir and other tech companies are stocking offices with nicotine products to increase worker productivity. Fortune. https://fortune.com/2026/03/04/palantir-tech-companies-offices-vending-machines-tobacco-worker-productivity/
[2] Hashibe, M., Brennan, P., Chuang, S.-C., Boccia, S., Castellsague, X., Chen, C., Curado, M. P., Dal Maso, L., Daudt, A. W., Fabianova, E., Fernandez, L., Wünsch-Filho, V., Franceschi, S., Hayes, R. B., Herrero, R., Kelsey, K., Koifman, S., La Vecchia, C., Lazarus, P., . . . Boffetta, P. (2009). Interaction between tobacco and alcohol use and the risk of head and neck cancer: Pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers & Prevention, 18(2), 541–550. https://doi.org/10.1158/1055-9965.EPI-08-0347
[3] Cho, E. R., Brill, I. K., Gram, I. T., Brown, P. E., & Jha, P. (2024). Smoking cessation and short- and longer-term mortality. NEJM Evidence, 3(3), EVIDoa2300272. https://doi.org/10.1056/EVIDoa2300272
[4] Marron, M., Boffetta, P., Zhang, Z.-F., Zaridze, D., Wünsch-Filho, V., Winn, D. M., Wei, Q., Talamini, R., Szeszenia-Dabrowska, N., Sturgis, E. M., Smith, E., Schwartz, S. M., Rudnai, P., Purdue, M. P., Olshan, A. F., Eluf-Neto, J., Muscat, J., Morgenstern, H., Menezes, A., . . . Hashibe, M. (2010). Cessation of alcohol drinking, tobacco smoking and the reversal of head and neck cancer risk. International Journal of Epidemiology, 39(1), 182–196. https://doi.org/10.1093/ije/dyp291
[5] Agaku, I. (2026). Tobacco product use among U.S. adults, 2023–2024. NEJM Evidence. https://doi.org/10.1056/EVIDpha2500339
[6] Park-Lee, E., Dutra, L. M., Cowan, H., Levine, B., Sawdey, M. D., Cooper, M., Merson, B., Valverde, R., Bradfield, B., Lennon, J., Freedman, N. D., Ambrose, B. K., & Cullen, K. A. (2026). Tobacco product use among middle and high school students in the United States: National Youth Tobacco Survey, 2025. Nicotine & Tobacco Research. Advance online publication. https://doi.org/10.1093/ntr/ntag116
[7] U.S. Department of Health and Human Services. (2016). E-cigarette use among youth and young adults: A report of the Surgeon General. Office of the Surgeon General. https://www.ncbi.nlm.nih.gov/books/NBK538680/
[8] Lindson, N., Livingstone-Banks, J., Butler, A. R., McRobbie, H., Bullen, C. R., Hajek, P., Wu, A. D., Begh, R., Theodoulou, A., Ma, C., Notley, C., Rigotti, N. A., Turner, T., Fanshawe, T., & Hartmann-Boyce, J. (2026). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, 8, CD010216. https://doi.org/10.1002/14651858.CD010216.pub11
[9] Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Myers Smith, K., Bisal, N., Li, J., Parrott, S., Sasieni, P., Dawkins, L., Ross, L., Goniewicz, M., Wu, Q., & McRobbie, H. J. (2019). A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine, 380(7), 629–637. https://doi.org/10.1056/NEJMoa1808779
[10] Goniewicz, M. L., Smith, D. M., Edwards, K. C., Blount, B. C., Caldwell, K. L., Feng, J., Wang, L., Christensen, C., Ambrose, B., Borek, N., van Bemmel, D., Konkel, K., Erives, G., Stanton, C. A., Lambert, E., Kimmel, H. L., Hatsukami, D., Hecht, S. S., Niaura, R. S., . . . Hyland, A. J. (2018). Comparison of nicotine and toxicant exposure in users of electronic cigarettes and combustible cigarettes. JAMA Network Open, 1(8), e185937. https://doi.org/10.1001/jamanetworkopen.2018.5937
[11] Tattan-Birch, H., Hartmann-Boyce, J., Kock, L., Simonavicius, E., Brose, L., Jackson, S., Shahab, L., & Brown, J. (2022). Heated tobacco products for smoking cessation and reducing smoking prevalence. Cochrane Database of Systematic Reviews, 1, CD013790. https://doi.org/10.1002/14651858.CD013790.pub2
[12] Heishman, S. J., Kleykamp, B. A., & Singleton, E. G. (2010). Meta-analysis of the acute effects of nicotine and smoking on human performance. Psychopharmacology, 210(4), 453–469. https://doi.org/10.1007/s00213-010-1848-1
[13] Mallock, N., Schulz, T., Malke, S., Dreiack, N., Laux, P., & Luch, A. (2024). Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches. Tobacco Control, 33(2), 193–199. https://doi.org/10.1136/tc-2022-057280
[14] U.S. Food and Drug Administration. (2026, June 30). FDA authorizes 20 ZYN nicotine pouches to be marketed with specific modified risk claim. https://www.fda.gov/tobacco-products/ctp-newsroom/fda-authorizes-20-zyn-nicotine-pouches-be-marketed-specific-modified-risk-claim
[15] National Health Service. (n.d.). Mouth cancer: Symptoms. Retrieved October 31, 2026, from https://www.nhs.uk/conditions/mouth-cancer/symptoms/