4 experts share insights from Sweden’s experience on the changing nicotine and public health landscape
- Last updated: August 29, 2025 | 19:14
Sweden offers a unique model in handling nicotine products and their impact on public health, drawing on a long history with tobacco.
In a special discussion, several experts and officials addressed key questions regarding the relationship between nicotine use and smoking, highlighting the concept of "harm reduction" as an effective public health strategy.
This article presents the perspectives of four experts and representatives—Dr. Joseph Ashkar, Professor Karl Fagerström, Patrick Strömmer, and Samuel Lundell—to provide a deeper understanding of the dynamics behind this transformation.
Nicotine and Smoking: A Medical Perspective
Dr. Joseph Ashkar, a cardiologist and internal medicine specialist, emphasized that Sweden’s significant decline in smoking-related diseases is primarily due to a reduction in the number of smokers, rather than an overall decrease in nicotine use. The core issue lies in how nicotine is consumed; inhaling it through cigarettes is the main cause of serious chronic illnesses, such as chronic obstructive pulmonary disease (COPD), lung cancer, and peripheral vascular diseases. Ashkar explains that the method of consumption is the decisive factor.
This explains how Sweden has achieved a reduction in smoking-related conditions while nicotine use remains widespread in alternative forms, such as nicotine pouches. Although these pouches are not risk-free, they are considered “harmful” to a much lesser extent than cigarette smoke. Ashkar notes that while nicotine is always harmful compared to non-use, it is significantly less harmful than smoking, aligning with the principles of harm reduction.
Regarding youth, Dr. Ashkar points out the lack of official research on younger age groups but suggests that nicotine may affect brain development due to its interaction with brain receptors, recommending that individuals under 18 or 21 avoid its use. He also warns people with pre-existing health conditions, such as type 2 diabetes, to avoid nicotine products due to potential negative cardiovascular effects.
Understanding Nicotine Dependence and the Role of Harm Reduction
Professor Karl Fagerström, inventor of the Fagerström Test for Cigarette Dependence, offered an in-depth perspective on the nature of nicotine addiction and its historical development. In the 1970s, when he began exploring this field, nicotine was not well understood, and smoking was generally viewed as a bad habit.
Fagerström later recognized a pharmacological dependence on nicotine beyond mere habit, leading him to develop a test to measure the severity of dependence rather than simply diagnose it. The test assesses dependence intensity: the higher the score, the harder it is to quit smoking, especially for individuals with other mental health challenges.
He highlights that the time taken to consume nicotine after waking is a sensitive indicator of dependence. Fagerström differentiates between behavioral and pharmacological dependence, noting that products addressing both aspects are more effective for quitting. For example, nicotine patches do not create significant dependence because they do not deliver a rapid nicotine spike to the brain, unlike cigarettes or e-cigarettes, which provide fast delivery and strong sensory effects that reinforce behavioral dependence.
Fagerström asserts that products such as heated tobacco, vaping, and nicotine pouches (smokeless tobacco) cause much lower dependence than cigarettes, supporting the harm reduction strategy. Very few smokers follow an immediate cessation approach; instead, he advocates a strategy that provides both behavioral and pharmacological support to aid quitting.
Sweden as a Model: Industrial and Societal Perspective
Patrick Strömmer, Secretary-General of the Swedish Snus Manufacturers Association, offered an industry view on the legislative landscape and cultural challenges for nicotine products in Sweden. Strömmer acknowledges that Swedish regulations are generally strong but still need improvements regarding underage monitoring and nicotine pouch regulation. He notes that the industry set its own quality standards—including age limits, health warnings, and marketing restrictions—before official laws were enacted.
Strömmer emphasizes that Sweden has successfully reduced daily smoking rates, stating, “We are making significant steps toward becoming a smoke-free country, and what we offer is a key part of this transition.” Studies indicate that nicotine pouches present a lower-risk alternative compared to traditional cigarettes, as research shows that alternative nicotine products do not carry the same health risks as conventional smoking.
Strömmer explains that Sweden has demonstrated success in reducing traditional smoking rates: “These statistics cannot be ignored. We cannot continue to equate ‘smokeless tobacco’ with conventional smoking when this comparison contradicts scientific reality.” He believes Sweden offers a successful model for implementing harm reduction policies, which could be applied in other regions, such as the Middle East, provided consumers have access to appropriate products and information.
Consumer Voice: Awareness and Challenges
From the user perspective, Samuel Lundell, Chairman of the Swedish National Association of Smokeless Tobacco Users, shared his insights on the benefits of nicotine pouches as an alternative to traditional tobacco in terms of user experience and harm reduction. Lundell highlights the wide range of flavors and ease of use as major factors, noting that the ability to use these products anytime and anywhere is a significant advantage, especially in cold climates.
He believes his organization’s role is to highlight the vast differences in health impacts between products to make the choice easier for consumers. Users of snus face legislative challenges, but Lundell sees opportunities to advocate for smokeless tobacco as a safer product and a job creator. He also addresses common misconceptions, such as the belief that all nicotine products are extremely strong or cause nausea, specifically refuting the notion that smokeless tobacco causes severe diseases.
Lundell notes that smokeless tobacco may cause minor, temporary changes in the gums due to direct contact. He observes that user behavior evolves: former smokers may use pouches longer to achieve their usual nicotine dose, but importantly, they avoid the more harmful risks associated with smoking.