Sweden is setting an unprecedented example by becoming the world’s first country to be declared smoke-free, as the nation’s smoking rates have plummeted from 15% to a mere 5.6% over the past 15 years. This milestone achievement is not only 17 years ahead of the European Union’s target but also a result of the country’s unique approach to tobacco control that diverges from traditional methods.
The success of Sweden’s smoke-free initiative can be attributed to a three-pronged approach: making alternative tobacco products widely available, a robust education program, and effective tobacco control measures. Instead of restricting or banning reduced-risk alternatives to cigarettes, the Swedish government has embraced them, particularly snus and nicotine pouches.
Snus, a moist oral tobacco product placed inside the upper lip, has a long history in Sweden, heavily outweighing smoking a century ago. Its use declined, but made a significant comeback from the 1970s, overtaking smoking once again in the 90s. The government has been incentivizing people to switch from cigarettes to snus through tax measures.
Nicotine pouches, an oral nicotine product that does not contain tobacco, are also gaining popularity. Swedish Match, the world’s leading snus producer, also manufactures Zyn, an increasingly popular nicotine pouch. As of 2020, 2.3 percent of U.S. adults reported using a smokeless tobacco product like snus or nicotine pouches either “every day” or “some days”.
The rates of smoking in Sweden have been rapidly declining, falling among men from 40 percent in 1976 to 15 percent in 2002, and among women from 34 percent to 20 percent over the same period. These rates have continued to fall, as the prevalence of snus, especially among men, has correspondingly increased, indicating a clear substitution effect.
The health benefits of this shift away from smoking are evident. Swedish lung cancer deaths are less than half the EU average, and overall cancer rates are 41% lower than the rest of Europe. Studies have shown that lung cancer and heart disease rates have dropped, particularly for men, and have remained at low levels compared to other developed countries with a long history of tobacco use.
The acceptance of alternative tobacco products has been slow in some quarters. As Dr. Karl Erik Lund, a senior researcher at the Norwegian Institute of Public Health, has noted, “It has been difficult [for tobacco control people] to accept that availability to snus may have greater impacts in reducing smoking than the regulations we have spent a lifetime fighting for”.
Despite the success of snus and nicotine pouches in reducing smoking rates, the sale of snus has been banned in the EU since the early 1990s, with Sweden being the only exception due to an exemption. This has driven Swedish Match and other producers to focus their efforts on markets such as the U.S. where these products are permitted. However, nicotine pouches, which are essentially identical to tobacco snus but contain plant fiber instead of tobacco – are seeing a rapid increasing in popularity. Part of this has to do with the fact that since it doesn’t contain tobacco, it is allowed within the EU. This has resulted in a surge in the popularity of nicotine pouches in the EU in recent years.
The shift in the nicotine industry, much like the change from gas-powered cars to electric, is still suspect and often unwelcome. Yet, as David Sweanor, an independent tobacco industry expert and adjunct professor at the University of Ottawa, has emphasized, technological transformation is crucial to risk reduction and should not be feared.
As Sweden stands poised to become the world’s first smoke-free country, it provides a compelling case study in the role of alternative tobacco products inpublic health and tobacco control. With its broad use of snus and nicotine pouches, Sweden is not only drastically reducing the number of smokers but also lowering the incidence of tobacco-related diseases, proving that a different approach to tobacco control can lead to better health outcomes. As other countries strive to achieve similar goals, they may well look to Sweden as a model for effective, innovative strategies in the quest for a smoke-free world.
