Probably looking at the TPD, a letter to MEPs warns about new nicotine products, but uniformly regulating all of them as combustible tobacco could undermine public health efforts to reduce smoking, ignoring the evidence of less harmful alternatives.
In a recent letter addressed to the “current and future members of the European Parliament,” Helen Stjerna and Cornel Radu-Loghin, Secretary Generals of A Non Smoking Generation and the European Network for Smoking Prevention (ENSP), respectively, expressed deep concerns about the impact of new nicotine products on European youth.
The letter particularly targets Sweden, a country on the verge of becoming the first in the world to declare itself “smoke-free” thanks to oral nicotine products, thus demonstrating a viable path for a successful battle against smoking-related diseases.
The definition of a tobacco-free society advocated by the WHO involves achieving a smoking rate below 5%. According to data from the Swedish Public Health Agency, smoking rates have steadily decreased over the past few decades, nearing 5% in 2023, while the use of alternative nicotine products has increased.
In 2015, Sweden’s smoking rate was 12%, while the global average was approximately 25.2%. However, in the past 15 years, Sweden has reduced its smoking rate from 15% to 5.6% (in the 1980s, it reached 35%). Meanwhile, the global average remains approximately 23%.
A survey conducted in 2020 revealed that the overall prevalence of smoking among Swedish adults (aged 16 to 84) was already one of the lowest in Europe, at around 7%. Among men, the prevalence of smoking was 8%, while among women it was 6%.
In contrast, about 19% of adults in Sweden reported daily use of oral nicotine products, with higher usage rates among men (29%) compared to women (8%), and approximately 5% confirmed daily use of electronic cigarettes.
Seeking to ignore the causes of this achievement, Helen and Cornel argue in the letter that the progress in reducing smoking in Sweden is primarily due to disseminating knowledge, taxation, and tobacco legislation. However, comprehensive studies and official data have shown that the use of snus has been a significant factor in the decline of smoking prevalence in Sweden.
Evidence vs. Simplification
The letter, which came into our hands from an individual who requested anonymity, mentions that the introduction of nicotine pouches has led to a generation of young Swedes developing a harmful nicotine addiction. While health experts emphasize the need to monitor the use of these products among youth, evidence suggests that the increase in the use of nicotine products among young people may be related to the reduction in the use of traditional cigarettes. Several studies indicate that young people who use non-combustible nicotine products, such as snus or electronic cigarettes, are less likely to transition to smoking conventional cigarettes.
In this context, the argument by Helen Stjerna and Cornel Radu-Loghin that new nicotine products act as a gateway to smoking is controversial and not supported by most research. Studies show that young people who use electronic cigarettes or snus often do so instead of, rather than in addition to, smoking traditional cigarettes. This phenomenon is known as “displacement” rather than a “gateway.”
The letter mentions that nicotine is a “poison” that increases the risk of “mental and deadly diseases.” Although nicotine is not harmless and can be addictive, science teaches that the vast majority of health harms related to tobacco come from combustion products, not nicotine itself. Harm reduction is a key strategy in public health that recognizes that while nicotine causes dependence, products that do not involve combustion are significantly less harmful than cigarettes.
Even so, the letter urges MEPs to follow WHO recommendations to regulate all nicotine products as tobacco unless they can be classified as pharmaceuticals. This stance ignores the growing evidence on the role of non-combustible nicotine products in tobacco harm reduction and the disruptive nature of consumer products that benefit public and individual health without pharmaceutical industry interference. Experts like Clive Bates point out that overly restrictive regulation of these products could lead to unintended consequences, such as an increase in the black market and a return to traditional cigarette smoking.
According to the study “Patterns of Smoking and Snus Use in Sweden: Implications for Public Health,” conducted by Lars Ramström, Ron Borland, and Tom Wikmans, the widespread use of Snus has had a significant impact on smoking habits in Sweden. The findings indicate that snus has contributed to a decrease in smoking initiation rather than acting as a gateway to smoking. Smokers who have adopted the use of snus have quit smoking at a significantly higher rate than those who do not use snus, and a considerable portion of them have also stopped using snus, becoming nicotine-free individuals.
According to scientists, these effects have been consistent over five decades and across different frequencies of snus use. Prolonged and daily dual use (tobacco and snus) is uncommon, and in general, dual-use seems to be a transitory state that does not hinder the motivation to quit smoking but acts as a step towards cessation. For both men and women, quit rates are significantly higher for those with a history of snus use compared to those without such a history.
Snus is the most common self-treatment method for quitting smoking in the Scandinavian country, and quit attempts using snus as an aid have a significantly higher success rate than those using other methods. All these effects have favorable public health consequences, suggesting that snus has been a critical factor behind the record low smoking prevalence in Sweden and its position as the country with the lowest tobacco-related mortality rate among men in Europe, according to an analysis of data from a WHO report.
2024-05Practical Lessons from the Swedish Approach
Sweden has demonstrated that adopting harm reduction strategies can be highly effective in the fight against smoking.
The report “The Swedish Experience,” conducted by a team of renowned researchers, including Karl Fagerstrom, Anders Milton, and Delon Human, analyzes how Sweden has achieved one of the lowest smoking rates in the world. It details the public health policies and harm reduction strategies that have been implemented. The report highlights the importance of snus and other smoke-free alternatives in reducing smoking rates. It guides how different countries can apply these strategies to lower smoking prevalence and improve public health.
Even other European countries have much to learn from the Swedish approach, which has achieved impressive results in reducing tobacco consumption.
Firstly, there is the issue of accessibility and acceptability. In Sweden, non-combustible nicotine products, such as snus, nicotine pouches, and electronic cigarettes, are readily available and affordable. This has made it easier for smokers looking to quit tobacco to find less harmful and acceptable alternatives for daily use. The availability of these products has been a fundamental pillar for those who wish to quit smoking, providing them with options that are not only accessible but also socially accepted.
Secondly, public education has been vital. The “Quit Like Sweden” platform has focused on informing the population about the relative risks of different nicotine products and promoting less harmful alternatives as a viable option for quitting smoking. This initiative aims to change perceptions and behaviors by educating citizens about the benefits of harm-reduction products. Through clear and evidence-based information, the campaign has empowered people to make informed decisions about their health.
Finally, Sweden’s fiscal strategy has played a crucial role. In Sweden, taxes on less harmful alternatives are significantly lower than taxes on cigarettes. This fiscal difference is not accidental; it is designed to incentivize smokers to switch to less damaging options. By making non-combustible nicotine products more economically accessible, the Swedish government has created an environment where it is easier and less costly for smokers to quit traditional cigarettes.
The Role of Public Education and the “Quit Like Sweden” Approach
Misinformation often distorts public perceptions of the risks associated with non-combustible nicotine products. Public education plays a crucial role in changing these perceptions, and the “Quit Like Sweden” platform addresses this challenge by disseminating evidence-based information about the relative risks of different nicotine products and the benefits of harm-reduction products.
Firstly, it is crucial to implement regulatory differentiation. Non-combustible nicotine products should be regulated differently from combustible tobacco products. This differentiation acknowledges their lower risks and their potential to help reduce smoking. By treating them differently, strategies can be promoted that genuinely benefit public health rather than merely following an unnuanced prohibitionist logic.
Additionally, it is essential to design fair fiscal strategies. Implementing lower taxes for harm-reduction products compared to traditional cigarettes will incentivize smokers to switch to less harmful alternatives. This fiscal policy will not only make safer options more accessible but also discourage the consumption of combustible tobacco products, which are significantly more damaging.
Strict regulations should also be established to limit youth access to these products. This includes implementing age restrictions and rigorous sales controls. However, it is equally essential to ensure that adult smokers have access to these alternatives, thereby facilitating their transition from traditional cigarettes to less harmful options. Protecting the youth should not mean penalizing adults who are seeking to quit smoking.
Lastly, it is vital to fund and support public education campaigns. These campaigns should inform the population about the relative risks of nicotine products and promote less harmful alternatives as viable and safe options for quitting smoking. Misinformation and myths are potent enemies in the fight against tobacco smoking, and only through transparent and evidence-based education can perceptions and behaviors be effectively changed.
The evidence is clear: a regulatory and educational approach based on harm reduction can transform the fight against smoking. Adopting measures recognizing product differences and promoting less harmful alternatives is essential for advancing public health.
Stjerna and Radu-Loghin’s Simplification is a Health Risk
Despite Helen Stjerna and Cornel Radu-Loghin’s concerns, addressing arguments with a critical and evidence-based perspective is essential. The insistence on regulating all nicotine products as equivalent to traditional cigarettes ignores the vast amount of research supporting the use of non-combustible nicotine products as an effective harm-reduction strategy.
The monolithic approach suggested by the letter, which does not distinguish between the different risks associated with nicotine products, seems to be a dangerous simplification. Equating reduced-risk products like snus and nicotine pouches with combustible cigarettes is a tactic that could have devastating consequences for public health. It not only discourages smokers from switching to safer alternatives but could also push current users of non-combustible products back to cigarettes, thereby exacerbating the health problems it supposedly aims to mitigate.
A scientist, who preferred to remain anonymous for fear of reprisals, added that the demonization of nicotine per se, without considering the context of its use, reflects a limited and myopic understanding of addiction and public health. “The true villains in tobacco consumption are the smoke and toxins released during combustion. Ignoring this distinction is ignoring decades of scientific advancements and hindering progress in the fight against smoking.”
The scientist warns that the policies proposed by the letter also “overlook the realities of human behavior and the market. Strict prohibitions and uniform regulations do not eliminate demand; they shift it to illegal and unregulated markets, where the risks are even greater, and government control is nonexistent.” History has repeatedly shown that total prohibitions are rarely effective and often create more problems than they solve.
“Instead of following a prohibitionist approach, European lawmakers should consider an evidence-based approach that balances the need to protect youth with the need to offer viable and less harmful alternatives to adult smokers. The Swedish experience, with its success in reducing smoking by promoting non-combustible nicotine products, offers a clear and proven model of how these objectives can be achieved simultaneously.”
While Stjerna and Radu-Loghin’s letter ostensibly seeks to protect European youth, their proposals could paradoxically result in more harm than benefit. Nicotine product regulation must be based on a nuanced and scientific understanding of risk, promoting safer and more effective alternatives for adult smokers rather than a punitive approach that ignores the complexity of addiction and human behavior. “The simplification that Stjerna and Radu-Loghin present to European parliamentarians is a health risk,” concludes the scientist.