In the countries where smoking is falling fastest, it is not taxes, bans or restrictions that are driving the decline. A growing number of reports now point to the switch to alternative nicotine products as the common denominator, although this is happening in tandem with other more official measures. This is particularly evident in the UK, New Zealand, the US, but also in Norway, where young people are choosing snus and e-cigarettes over cigarettes.
"We will soon see the first smoke-free generation in Norway," says tobacco researcher Karl Erik Lund.
Vejpkollen is monitoring E-cigarette summit 2022 in London
Reporter: Stefan Mathisson
In England, USA and New Zealand it is about e-cigarettes. In Sweden and Norway, it's snus and nicotine pouches. Cigarettes as the main source of nicotine are simply being phased out and replaced by new products, says Karl Erik Lund, together with representatives from New Zealand and the UK. This phenomenon is particularly evident among young people. Vejpkollen has previously reported on the situation in New Zealand and England. But it also happens in Norway.
"Smoking has virtually disappeared among our young people in Norway. Less than two percent smoke and cigarettes are no longer part of the youth culture. We can safely assume that the new generation will not contribute to more smokers in society." says Norwegian tobacco and addiction researcher Karl Erik Lund under E-cigarette Summit 2022 in London.
"Smoking no longer a youth culture"
Karl Erik Lund is employed as an investigator at the Norwegian Institute of Health. We meet in the foyer of The British Medical Association magnificent building in central London. E-cigarette summit 2022 is happening all around us. Researchers, health scientists, activists, politicians are mingling with users, tobacco company representatives and journalists. It's a somewhat unusual gathering, as conferences tackling nicotine and smoking issues are often tightly divided between industry, academia and policy makers.
Tools to reduce risks
For anyone interested in harm reduction, be it smoking or other harmful habits, the Royal College of Physicians is more or less sacred ground. It was here that the blueprint for the UK strategy for tobacco harm reduction was published almost 10 years ago. The report "Nicotine without smoke" from 2016 (and again in 2020) confirmed what many doctors, researchers, activists and commentators have been saying for years: if you separate the nicotine from the combustion of tobacco, only marginal health risks remain for the user. Getting smokers to switch to smoke-free alternatives should therefore be priority ONE in the fight against the harmful effects of smoking, said Royal College of Physicians.
But of course, it would not be quite that simple.
Only accepts nicotine medicines
Outside the UK and New Zealand, the bodies set up to combat smoking in society systematically view harm reduction for smokers with skepticism. At best, as a unproven method, at worst, as a kind of myth spread by the tobacco companies to protect their sales.
"You don't talk about relative risks of harm as long as there are evil tobacco companies with an interest in selling the products. Nicotine medicines are the only thing that is really accepted when substitutes are discussed," says Karl Erik Lund.
"The protector of snus"
Karl Erik Lund has long studied smoking in relation to alternative nicotine products in Norway. He has sometimes been called the "protector of snus" in Norway. Not that he has any connection whatsoever with either industry or some lobby organizations. Rather, his research suggests that smoke-free products actually attract those who are, or may become, smokers away from cigarettes. That this can have important consequences for public health.
"For a long time I was skeptical about new products containing nicotine. But there is no denying that nicotine use in the form of snus and e-cigarettes has significantly less harm than smoking. And we will see this as new generations quit smoking and switch to other products." Karl Erik Lund.
New products challenge cigarettes
Unlike his colleagues at the Norwegian Health Authority, Karl Erik Lund sees the development in Norway in a positive light, and as something quite different from just the result of harsh anti-smoking campaigns. He sees the decline in smoking as a direct consequence of the introduction of new, and attractive, tobacco products, nicotine products emerge on the market.
"Statistics show that the proportion of young people who smoke has been steadily decreasing for 30 years, but it is only at the end of the 1990s that the curve begins to slope steeply downwards." says Karl Erik Lund.
This is when the new portioned snus was launched, with new flavors, and in a more user-friendly format (portion bags instead of bulk). At the same time, companies sent a clear message that snus is less harmful than smoking.
A popular way to quit smoking
But that is only part of the explanation, says Karl Erik Lund. Traditional measures have also played a role.
"Taxes on cigarettes were raised sharply. Smoking was also banned in many public places. In a country like Norway, not having to go outside to get your nicotine was obviously attractive to many people. Snus quickly became the most popular way to quit smoking, especially for older smokers who didn't like traditional methods like nicotine gum and patches." he says.
Nicotine portions creep under the law
But the really big change among young people occurred just a few years ago, long after snus became popular in Norway, says Karl Erik Lund.
It was then that the new nicotine pouches appeared on the market.
Nicotine pouches in Norway are different from the rest of the world. In addition to plant cellulose, they also contain a small amount of tobacco. The explanation for this lies in the Norwegian legislation on nicotine. Since the mid-1990s, the government has not approved any new nicotine-containing products on the market, except for nicotine medicines. Cigarettes and snus were already regulated and were of course allowed to remain. When companies wanted to launch fully synthetic nicotine pouches, they soon found a loophole and exploited it to the full. With one percent tobacco in the nicotine pouch, it becomes snus by definition and can be sold as snus. Other new nicotine products, such as e-liquid, e-cigarettes with nicotine are still banned, although the law is currently in the process of changing.
"We have a very strange and old-fashioned legislation. It doesn't really work, without exaggerating" says Karl Erik Lund.
A fly among the young
In 2020, white snus, with all its flavors, became a real fad among young people. It is this development Karl Erik Lund come to be most interested in.
"Snus use among young people rose rapidly, while smoking declined. It soon became clear that it was primarily young people who were already smoking who started using snus. We can also assume that the small proportion who were initially non-smokers were probably at risk of taking up smoking anyway. Snus may have had a diversionary effect on these young people, but for obvious reasons we cannot point to a direct causal link," says Karl Erik Lund.
A smoke-free generation - the 'wrong' way
Somewhere here things get really problematic. Norway has had a smoke-free generation. But it didn't happen in the way it was "supposed to". Under the model that prevails in traditional control devices smoking would be discouraged with high taxes, reduced demand through good role models and dreams of a healthier lifestyle. Moreover, the root of the evil, tobacco companies' profits, would disappear as their products became unwanted.
From smoke-free to nicotine-free
Now smoking is disappearing, but the tobacco companies are still there, nicotine is still popular and someone is making money from it. This is not helped by the fact that a government-employed tobacco researcher points out that it can actually be a positive development that young people use snus instead of smoking. A sensitive point, he notes.
"As smoking declines, the narrative trumpeted by established control agencies has changed. It is not clearly stated, but the goal has shifted from a 'smoke-free' to a 'nicotine-free' society. However, there is no doubt that low-risk products such as snus will reduce the harm from continued nicotine use. It has done so in Sweden and there is no reason to believe that we will not see a similar development in Norway." says Karl Erik Lund.
An ideological reflex
As I said, the reaction from the traditional control apparatus is anything but positive. Tougher rhetoric and demands to more or less eliminate all use of nicotine are being made in Norway, Sweden, the rest of the EU and, in fact, the whole world. The message is spread in the media, lobbied against politicians, against doctors and health workers, against researchers seeking funding. Snus and e-cigarettes have become the target, more often in the crosshairs than cigarettes. It is a backlash that Karl Erik Lund interpreted more as a spinal reflex than a scientifically based position.
"The crux of the matter" according to Karl Erik Lund"is that the harms of nicotine use will decrease dramatically as the market changes"
Affected by interests other than public health
This obviously affects the incentive to limit use, which can have economic consequences for the institutions working in the field, he says. Decisions on nicotine, smoking and harm reduction are therefore likely to be influenced by interests other than a pragmatic concern for public health.
"What is happening has been very difficult to accept for people who have fought for decades, sometimes entire careers, to push for tougher laws to curb tobacco use. Their efforts have certainly had a huge impact, but they did not go all the way. New technologies and products have proved to be equally, if not more, important in creating the smoke-free society. And it is catching on," says Karl Erik Lund.
The issue affects the whole of society
But what happens next? Karl Erik Lund asks the audience in the packed hall of the Medical Society's auditorium. The answer to that question depends on how the issue is handled, and who participates in the discussion.
"New blood is needed in the debate. Fortunately, we see that the discussion is actually spreading beyond these historically closed groups within the control apparatus. Today, the discussions are taking place in political forums, in think tanks, in political parties and even in government. This is useful. Harm reduction is an issue that concerns the whole of society, not just a small group"
Consumers' voices matter
However, Karl Erik Lund believes that the most important element in the debate on nicotine and harm reduction will be the voices of consumers.
"I suspect that the strongest argument for keeping harm-reducing products, such as snus and e-cigarettes, in the smoke-free society is the right to actually use nicotine if you want to. The issue of self-determination and personal freedom is central. At least at a time when smoking is disappearing from the equation and harm-reducing products are taking over. As they have done among young people today" says Karl Erik Lund.
