INTRODUCTION

The whole world is watching Sweden as it stands on the brink of one of the greatest public health achievements in centuries.

The Scandinavian country is waiting on fresh statistics that may show that it has become, officially, smoke-free. International organisations and experts define a country as being ‘smoke-free’ when less than 5% of its adult population smokes.

After years of declining smoking rates which have been the envy of its neighbours, the Swedes could become the EU’s first smoke-free country as early as next year – beating an EU target (which is set to be missed by every other member state) by an incredible 17 years. Sweden, which currently has a smoking rate of 5.6%, not only has the lowest smoking rate in the EU, having fallen by over 50% in the past decade, but also boasts the lowest incidence of tobacco-related cancers anywhere in the EU.

This achievement in becoming smoke-free is unmatched in any other country that had a previously high smoking rate. It means that the nation that invented the three-point seatbelt, and donated it to the world is, once again, an example for global public health campaigners.

In the run-up to the Framework Convention on Tobacco Control’s Tenth Conference of Parties (FCTC COP10), which will bring together delegations from every signatory in Panama this November, Smoke-Free Sweden toured the world to engage with international experts. The goal was to study how adult smokers in Sweden have saved millions of their lives. We visited Warsaw, Dhaka, Johannesburg, Stockholm and São Paulo.

And the message was clear and unequivocal: Sweden has made smokeless alternatives to cigarettes accessible, acceptable and affordable – and that’s what has been critical to its success in becoming smoke-free.

Key experts

• Dr Anders Milton, Sweden, Physician
• Dr Kgosi Letlape, South Africa, Physician
• Voice of Vapers, Bangladesh, Vaping Consumer Group
• Dr Konstantinos Farsalinos, Greece, Physician
• Carissa Düring, Sweden, Clinical Psychology Student, & Consumer Org Leader
• Dr Diego Verrastro, Argentina, Surgeon
• Francisco Javier Ordoñez, Colombia, Social Scientist
• Dr Delon Human, South Africa, Health Diplomats
• Dr Karl Fagerström, Sweden, Psychologist
• Dr Christopher Russell, United Kingdom, Behavioural Psychologist
• Dr Mihaela Răescu, Romania, Dentist
• Federico N. Fernández, Argentina, Economist & Consumer Org Leader
• Prof. Dr Marewa Glover, New Zealand, Tobacco Control Academic
• Joseph Magero, Kenya, Consumer Organisation Leader
• Kurt Yeo, South Africa, Consumer Organisation Leader

Key components of the Swedish experience

From our conversations with experts around the world, the clear consensus was that Sweden did things differently. We wanted to understand; how exactly has Sweden’s approach to alternative nicotine products led to its success? And how can we explain why tobacco control and education measures alone are not enough to reduce smoking prevalence? The Smoke-Free Sweden movement came away with some clear insights:

#1 Embracing harm reduction strategies

There is wide access to alternative reduced-risk products. In Sweden, snus, oral nicotine pouches, e-cigarettes, and heated tobacco are all widely available and can be bought both on and offline, and the government has publicly recognised the “relative risk” of all tobacco and nicotine products categories. This is in keeping with Article 1 (d) of the WHO Framework Convention on Tobacco Control, which calls for harm reduction strategies to complement tobacco control. In Sweden, policy settings support the adoption of reduced-harm, smoke-free alternatives by making them more affordable than the most harmful combustible cigarettes. This eliminates financial barriers to switching away from cigarettes.

#2 Accurate risk communication

Sweden has provided accurate risk communication to consumers about alternative smoke-free products and their relative low risk. This is an important factor in helping smokers switch to less harmful products. Misinformation is a clear barrier to reducing smoking prevalence: in the UK, despite the success of vaping, 4 in 10 current smokers still believe that vaping is equally as harmful as traditional cigarettes.

Bangladesh THR Summit: “These lives are real people. We need to put faces to them and understand that they are mothers, fathers, grandfathers, grandmothers. If you look at the life-years lost to disability, it’s massive! I can’t get my head around it. In New Zealand, we only have 5 million people. 4500 to 5000 die per year from smoking-related diseases. That’s enough! How can any health professional, policy analyst, or politician, how do they sleep at night when this could be prevented? We’ve always said for 30 years in tobacco control, smoking is the largest preventable cause of premature death and smoking-related diseases and disabilities. We knew it was preventable, and yet, the interventions, the strategies have been the least effective at preventing those disabilities and deaths. Why didn’t we choose and why are we not choosing to reduce these numbers faster? That’s what we need to be asking. This is absolutely unethical.” Prof. Marewa Glover

Bangladesh THR Summit: “We’re just here to share the science and information. It’s up to the Bangladeshi people to make that decision” Dr Marewa Glover

Stockholm Harm Reduction Event: “Authorities need to communicate honestly when it comes to new research on alternative nicotine products”. Dr Konstantinos Farsalinos

South Africa THR Summit: “a plethora of unvalidated information is muddying the waters not only of public perception, but also patient care”. Dr Derek Yach

#3 Access to reduced-risk nicotine products

Throughout the various events, health experts underscored the fact that Sweden has provided access to alternative products which is a huge component of Sweden’s success. As such, alternative smoke-free nicotine products provide consumers with reduced cigarettes consumption.

Several countries throughout the world – including many that battle a high smoking rate – have shown that their first instinct is to heavily ban or restrict alternative products. Sweden has not done this: all alternatives are available for purchase, giving smokers the opportunity to choose the alternative that suits them best.

South Africa THR Summit: “I think Sweden is now at that tipping point, where we start seeing that harm reduction is a viable route. You’ve got to a point in this smoking pandemic, if we can call it that, where we see the plateauing and now we need that next bit of innovation and the next bit of thrust to start eliminating combustion from this discussion about nicotine”. Kurt Yeo

Stockholm Harm Reduction Event: “Sweden has managed to become smoke-free by using alternative products. They did not eliminate nicotine”. Dr Konstantinos Farsalinos

Stockholm Harm Reduction Event: “Sweden is *the* nicotine country in the world. Nicotine replacement was invented in Sweden… nicotine pouches were also developed in Sweden”. Dr Karl Fagerström

#4 Facilitating consumer acceptance of smoke-free products

Making tobacco harm reduction work means creating alternative products that smokers will actually switch to. Sweden’s experience proves that tobacco harm reduction is a viable pathway. Yet there are several key elements of Sweden’s approach that should be remembered. Not only does Sweden have a wide range of alternative products, but these are available in multiple different nicotine concentrations and flavours.

Furthermore, Sweden’s Riksdag last year voted against a flavour ban for vapes. It is not simply a case of ‘set and forget’. Policymakers must remain dynamic and embrace new products and new approaches, and ensure that they are sufficiently palatable so that smokers would actually want to use them in place of cigarettes. In taking a pragmatic approach, Swedish policymakers have put themselves in a position to save millions of lives through the knock-on public health effects of low smoking rates.

What the world should know about Sweden: recommendations for policymakers

The upcoming COP meeting, as well as the revision of the EU’s Tobacco Products Directive (TPD), provide an opportunity to policymakers to fully examine the life-saving impact of the Swedish approach. WHO data shows clearly that Sweden’s incidence of cancer is 41% lower than the rest of its European counterparts, corresponding to a 38% lower level of total cancer deaths.

Sweden has a 39.6% lower rate of death of all tobacco-related diseases compared to the EU average. As a result of our ongoing research and collaboration with renowned experts from around the globe, we call on governments to take into consideration the Swedish case study and we propose a series of policy solutions to be taken into account by policymakers:

1. Harm reduction: Develop and embrace harm reduction strategies.
2. Implement risk-appropriate nicotine regulation: The Swedish model has proven to be a highly effective approach to tobacco control, leading to significantly reduced smoking rates and associated health issues.
3. Understand the life-saving benefits of the Smoke-Free Sweden model: Our research paper, Saving Lives Like Sweden, found that if every EU country followed Sweden’s approach and made safer alternatives affordable, acceptable and accessible to smokers, just under 3 million European lives could have been saved between 2000 and 2019.
4. Promote the Swedish experience globally: Encourage the widespread adoption of the Swedish model in other regions, highlighting its success in reducing smoking prevalence and the associated health risks, and promote the Swedish Experience at global fora such as the FCTC COP. This will contribute to the global efforts to reduce the harm caused by tobacco use.
5. Focus on quitting, or at least switching to smoke-free alternatives underpinned by clear information on relative risks: Our experts have emphasised the unequivocal potential benefits of utilising alternative nicotine products as a harm reduction strategy. The WHO must take note, and commission official research into what has made Sweden smoke-free 17 years ahead of the EU target.
6. Implement accurate risk communication: Policymakers at national, regional and global level should ensure that regulations make distinct risk-based differentiations between combustible and non-combustible nicotine products, so they cannot be treated equally. This approach will facilitate more accurate risk communication to consumers, enabling informed decision-making.
7. Accessibility, Affordability and Acceptability: Governments should pursue policies that will allow smoke-free products to be accessible, acceptable and affordable. Policymakers should consider implementing policies that would allow these products to become more accessible and acceptable to smokers, including the use of regulated flavours.