About one in four Swedes use nicotine products, which is comparable to the rest of Europe. But Sweden sees 44 percent fewer tobacco-related deaths per capita, according to a recent report. The difference, say the authors of “No Smoke Less Harm,” is that Sweden has embraced snus and nicotine pouches, both of which are smoke-free products that are far less harmful than cigarettes.
“Although nicotine may be dependence-forming, it does not cause cancer. Studies have long established this fact,” the report states. “Tragically, significant myths about nicotine persist among physicians and the public alike. The misperception of nicotine’s harms among healthcare professionals is unacceptable and not in the best interest of their patients. If health professionals don’t understand nicotine, how can we expect the public to know that nicotine does not cause disease?”
Co-author Karl Fagerström, the clinical psychologist who created the Fagerström Test to assess nicotine dependence among people who smoke, told Filter that the report highlights how—when Sweden consumes nicotine at the same rate as the rest of Europe yet suffers far fewer tobacco-related harms—nicotine is not the enemy.
“Europeans are ignorant or even misled” about the risks of nicotine consumption, Dr. Fagerström said. But he pointed out that this isn’t just a European problem. Around the world, including in the United States, research shows many clinicians still believe nicotine is causing cancer.
“By adjusting public understanding and regulations, we can mitigate health risks without having to resort to total bans.”
It’s a long-established fact that “People smoke for nicotine but they die from the tar,” as Professor Michael Russell famously wrote in 1976. It’s the combustion of tobacco that is deadly, releasing chemicals associated with at least 16 types of cancer.
“[By] adjusting public understanding and the regulations governing nicotine use, we can mitigate health risks without having to resort to total bans,” Fagerström explained.
In parts of Europe and elsewhere, reducing tobacco-related deaths has been equated with the idea of getting rid of nicotine completely. Swedes, however, have simply embraced a safer way of consuming it.
Snus has long been a part of Swedish culture. And when Sweden joined the European Union in 1994, it opted out of the bloc’s ban on snus in order to keep the product on the market.
Snus consists of small packets of tobacco that are placed between the upper lip and gum, to allow the user to absorb nicotine. Nicotine pouches, developed more recently, are used in exactly the same way but contain no tobacco, only nicotine extract. Researchers have estimated that use of this category of products is about 100 times less harmful than combustible cigarette use.
Previous research has shown Sweden’s uptake of snus is more prevalent among men, with 20.2 percent of men using the safer nicotine product compared to 7.2 percent of women. Data show lung cancer prevalence among Swedish men is less than half the average rate in the EU.
Sweden has embraced smokeless products so successfully that it will soon become the world’s first “smoke-free” country—meaning a national smoking rate of under 5 percent. The EU at large is not projected to attain that status until 2070, decades past its 2040 target.
Swedish tobacco harm reduction advocate Stefan Mathisson attributes Sweden’s success to the fact that at this point, “generations of smokers” there have had access to snus alongside cigarettes.
“It’s easier to learn to understand the concept of harm reduction, as it’s part of society here,” he told Filter.
“We did something different so we have different results … more people will get to keep their family members alive.”
Carissa During, the Sweden director for consumer advocacy group Considerate Pouchers, expressed a similar sentiment.
“It makes Sweden stand out in the world as a unique case study,” she told Filter. “We did something different so we have different results. Results that entails that more people will get to keep their family members alive.”
On November 1, Sweden will see tax changes on tobacco and nicotine. Tax on combustible products like cigarettes will increase by 9 percent, while the tax on snus will be reduced by 20 percent. That should make the less-harmful nicotine product more accessible, which might further accelerate smoking cessation.
The move indicates that the Swedish government recognizes the public health benefit of snus and nicotine pouches, and their important role in reducing smoking-related harms. What would it take for the rest of Europe to approach these products differently?
“I think the watershed, whether one accepts or believes in harm reduction, falls back on whether one thinks mankind can get rid of nicotine or not,” Fagerström told Filter. “If one believes that we can completely rid [ourselves] of nicotine it might [seem] counterproductive to go the harm reduction route.”
Image via Centers for Disease Control and Prevention