"The report does not provide users with clear information on relative risks. We only get assumptions and opinions that are not scientifically based. It bit a thumbnail"
This is what Karl-Åke Johansson and Samuel Lundell, active in the consumer-driven NNA Sweden and Snusarnas Riksförbund, say in a comment on the Public Health Agency of Sweden's report "Knowledge about the harmful effects of tobacco and nicotine products"
On June 30, the study on the harmful effects of various nicotine products that The Social Affairs Committee called for 2022. The task was to report knowledge about the risks of harm from different products and then compare the risks. But when the Public Health Agency of Sweden, together with SBU and the National Board of Health and Welfare presented its reportInstead, it was ignorance and a clear political message that shone through. At least that is what Samuel Lundell and Karl-Åke Johansson, active in two of Sweden's largest user associations for nicotine users.
"It is a sweeping statement to say that nicotine use is dangerous, and that legislation should be tightened overall. But at the same time they say they don't know enough to draw any conclusions about relative risks between snus, smoking, or vejpa. It is a study full of contradictions." says Samuel Lundell, Chairman of the National Snus Association to Vejpkollen.
Risk differences - despite lack of knowledge
According to the Public Health Agency, the state of knowledge is unclear for both snus (mainly nicotine pouches) and e-cigarettes in terms of risks. However, the risks of cigarette smoking are well documented, the report states.
Smoking increases the risk of several cardiovascular diseases, several cancers, type 2 diabetes, lung diseases, premature death, and in pregnancy: miscarriage, stillbirth, low birth weight, sudden infant death syndrome, according to the Public Health Agency of Sweden.
Fewer risks of snus use
The corresponding risks for snus are less well known and based only on Swedish studies, the investigators say. However, the risks appear to be much lower: increased risk of hypertension (as with all forms of nicotine use), some cancers (although there are no documented links), increased risk of type 2 diabetes (as with smokers), increased risk of death after a stroke (as with smokers). Pregnancy: increased risk of premature birth and disruption of the baby's respiratory regulation (overall fewer risks than smoking).
Unclear with vejpning
When it comes to the use of e-cigarettes, the FHM leaves many gaps in the tables. The risks it claims to know are: effects on heart rhythm, blood vessels and blood pressure, and exacerbation of asthma (according to small studies of perceived symptoms among smokers). According to the agency, there is a lack of knowledge about the risk of cancer, type 2 diabetes, pregnancy and premature death.
"Excludes 99 percent of research"
The Public Health Agency's own description of the source material shows that the investigators excluded many studies relating to the risks of different nicotine uses. Out of almost 6000 articles in the databases, only 18 remained after the screening process, the majority of which are comparisons. The Public Health Agency of Sweden attributes the lack of evidence to the risk of bias and research with underlying industrial interests.
"Instead of thoroughly reporting the research that exists, 99.7% of all research that actually exists on snus and e-cigarettes has been excluded. This is of course not true. If other investigations from the UK and New Zealand can handle the material, our Swedish investigators should be able to do so too," says Karl Åke Johansson, spokesperson for New Nicotine Alliance Sweden.
Difference with similar reports
According to similar reports from, for example British Public Health Agency contrary to the opinion of the Public Health Agency of Sweden, it is possible to scientifically establish clear differences in risk between different nicotine products. Since 2015, the UK authorities have been compiling relative health risks between smoking and vejpa and refers, among other things, to studies of biomarkers (substances in the body that increase the risk of diseases) and several randomized control trials involving smokers and vejp users in clinical settings.
"Vaping exposes the body to far fewer harmful substances than smoking. Vaping is not completely harmless, but it is a much safer way to use nicotine than smoking cigarettes," writes the UK Public Health Agency in its last updated report (2022)
However, the use of snus and nicotine pouches is not included in the UK compilation, at present.
"WHO is in the way"
Karl-Åke Johansson and Samuel Lundell believe that the Public Health Agency of Sweden has deliberately tried to avoid studies that would in any way show the relative risks of e-cigarettes and snus compared to smoking.
"The Public Health Agency refers to the WHO Tobacco Convention. The WHO is clear that harm minimization, which is based on relative risks between different nicotine products, is not desirable. They say that countries that have signed the Convention should fall in line. It doesn't matter if major institutions such as the British Medical Association and Chochrane reviews conclude otherwise. Asking the Public Health Agency of Sweden to investigate the relative risks of nicotine use would be like asking a hole in the ground to survey the sky," says Karl-Åke Johansson.
"Should complain about the report"
At the same time, Karl-Åke Johansson believes that the mission was very clear after all and that the agency has simply failed to carry it out, for whatever reason.
"It should be a useful basis for making decisions. This is mostly speculation based on very weak foundations and lined with the authority's negative view of nicotine use. They write that e-cigarettes MAY be dangerous in the long term, but only because there are no studies on long-term effects. It claims that vejp and snus use MAY lead to smoking, although it clearly states that a causal link cannot be established. But because nicotine CAN be dangerous, they choose to emphasize the risks, without discussing the differences between snus and smoking, for example. This is not what Parliament asked for. If I were a member of the Social Affairs Committee, I would reject the report and demand a new, functional product." Says Karl-Åke Johansson.
The authority pleads for more bans
In connection with the publication of the report, the Public Health Agency of Sweden also published a press release, highlighting the risks of nicotine use and calling for stricter legislation.
"All tobacco and nicotine products contain nicotine, which is toxic, highly addictive and can pose health risks. The Public Health Agency of Sweden believes that the availability of and demand for tobacco and nicotine products needs to be reduced, particularly to protect children and young people. "There is a need for regulation of these products that is more similar to the protective legislation that exists for tobacco smoking, including a ban on flavorings, regulation of nicotine content and marketing bans," says Director General Karin Tegmark Wisell in FHM press release.
"Similar to government activism"
Karl-Åke Johanson and Samuel Lundell believe that the agency's statement is at odds with the current government's ambition to introduce a harm minimization perspective in nicotine policy, an ambition that is also supported by a majority in the Riksdag. This was also the background to the investigation, they say.
"This looks more like government activism than anything else, unfortunately. I hope that wise politicians will put their foot down and demand a more ambitious review of the relative risks. It is clear that the agency has its own agenda here and that it has colored the work. This investigation should therefore be consigned to the dustbin." says Samuel Lundell, Snusarnas Riksförbund.
