How Sweden is set to become Europe’s first smoke-free country

Sweden is on the verge of becoming Europe’s first smoke-free nation.

A country is defined as smoke-free when less than five per cent of its people smoke every day.

While many credit the Swedish government for passing laws against smoking and conducting tireless anti-smoking campaigns, others credit the “snus.”

But how has Sweden managed this feat? And what is the snus?

Let’s take a closer look:

How Sweden managed this feat

Sweden is a country where smokers are rare.

Only 6.4 per cent of Swedes over 15 were daily smokers in 2019, the lowest in the EU and far below the average of 18.5 per cent across the 27-nation bloc, according to the Eurostat statistics agency.

Figures from the Public Health Agency of Sweden show the smoking rate has continued to fall since then, reaching 5.6 per cent last year.

“We like a healthy way to live, I think that’s the reason,” said Carina Astorsson, a Stockholm resident. Smoking never interested her, she added, because “I don’t like the smell; I want to take care of my body.”

The risks of smoking appear well understood among health-conscious Swedes, including younger generations.

Twenty years ago, almost 20 per cent of the population were smokers — which was a low rate globally at the time.

Since then, measures to discourage smoking have brought down smoking rates across Europe, including bans on smoking in restaurants.

“It’s very positive,” Swedish Health Minister Jakob Forssmed told AFP.

“A very important decision was the smoking ban in restaurants from 2005, and then at outdoor restaurants and public places in 2019,” he said.

Sweden has gone further than most to stamp out cigarettes, and says it’s resulted in a range of health benefits, including a relatively low rate of lung cancer.

“We were early in restricting smoking in public spaces, first in school playgrounds and after-school centers, and later in restaurants, outdoor cafes and public places such as bus stations,” said Ulrika Årehed, secretary-general of the Swedish Cancer Society.

“In parallel, taxes on cigarettes and strict restrictions on the marketing of these products have played an important role.”

She added that “Sweden is not there yet,” noting that the proportion of smokers is higher in disadvantaged socio-economic groups. The sight of people lighting up is becoming increasingly rare in the country of 10.5 million. Smoking is prohibited at bus stops and train platforms and outside the entrances of hospitals and other public buildings.

Like in most of Europe, smoking isn’t allowed inside bars and restaurants, but since 2019 Sweden’s smoking ban also applies to their outdoor seating areas.

WHO, the UN health agency, says Turkmenistan, with a rate of tobacco use below 5 per cent, is ahead of Sweden when it comes to phasing out smoking, but notes that’s largely due to smoking being almost nonexistent among women. For men the rate is 7 per cent.

WHO attributes Sweden’s declining smoking rate to a combination of tobacco control measures, including information campaigns, advertising bans and “cessation support” for those wishing to quit tobacco.

Tove Marina Sohlberg, a researcher at Stockholm University’s Department of Public Health Sciences, said Sweden’s anti-smoking policies have had the effect of stigmatizing smoking and smokers, pushing them away from public spaces into backyards and designated smoking areas.

“We are sending signals to the smokers that this is not accepted by society,” she said.

Paul Monja, one of Stockholm’s few remaining smokers, reflected on his habit while getting ready to light up.

“It’s an addiction, one that I aim to stop at some point,” he said. “Maybe not today, perhaps tomorrow.”

But others are looking at another source – Sweden’s beloved snus.

The snus

The snus, a highly addictive nicotine product, is a distant cousin of dipping tobacco in the United States.

Pronounced ‘snoose’, its users place small pouches of moist tobacco under their upper lips.

Swedes are so fond of it that they demanded an exemption to the EU’s ban on smokeless tobacco when they joined the bloc in 1995.

At the Swedish Match factory in the western city of Gothenburg, thousands of doses of snus wend their way through a complex web of machinery producing the sachets.

The company sold 277 million boxes of snus in Sweden and Norway in 2021.

“We have used it for 200 years in Sweden. (It’s) part of the Swedish culture, just like many other European countries have their wine culture,” Swedish Match spokesman Patrik Hildingsson told AFP.

Clad in a white lab coat, he described the manufacturing process.

“Tobacco comes from India or the United States. It goes through this silo and is then packed inside the pouches like tea bags and then into these boxes.”

There are two types: traditional brown snus, which contains tobacco, and white snus, which is made of synthetic nicotine and often flavoured.

Traditional snus is mostly sold in Sweden, Norway and the US.

White snus, introduced about 15 years ago, falls into a legal void in the EU since it doesn’t contain tobacco. It was banned this year in both Belgium and the Netherlands.

But it is hugely popular with young people in Sweden, with its use quadrupling among women aged 16 to 29 in four years.

Fifteen percent of people in Sweden say they use some form of snus daily, a figure that has risen slightly in recent years.

The government has also backed the snus industry, hiking taxes recently on cigarettes by nine percent while cutting those on traditional snus by 20 percent.

“With all these regulations it’s almost impossible to smoke. Snus doesn’t smell, and the nicotine rush is much stronger than with a cigarette,” said Thorbjorn Thoors, a 67-year-old window repairman who has used snus since his teens and quit smoking decades ago.

Swedish snus makers have long held up their product as a less harmful alternative to smoking and claim credit for the country’s declining smoking rates.

National Library of Medicine website, the number of men that smoke every day has dropped from 40 per cent in 1976 to 15 per cent in 2002.

Around a third of male smokers used snus while stopping their habit.

“Many Swedes also say that switching to snus helped them stop smoking,” Forssmed told AFP.

Snus, unlike smoking does not seem to cause cancer or respiratory illnesses in its users, as per the website.

Its usage may result in slightly higher cardiovascular risks and is possibly harmful to the foetuses of pregnant woman – though the risks remain lower than those due to smoking.

But health authorities remain disappointed in the government’s decision.

“It came as a complete surprise and I was really disappointed,” Ulrika Arehed Kagstrom, head of the Swedish Cancer Society, said.

“It shows that they really completely bought the fairytale from the tobacco industry, (which is) trying to find a new market for these products and saying that these are harm reduction products.

“We don’t have enough research yet,” she insisted.

“We know that snus and these kinds of nicotine products cause changes in your blood pressure and there is a risk of long-term cardiovascular disease.”

They are reluctant to advise smokers to switch to snus.

“Compared to cigarette smoking, the use of snus is probably less harmful,” Michael Steinberg, MD, MPH, director of the tobacco dependence program at Rutgers University told Web MD. “But there’s a big difference between ‘less harmful’ and safe.”

“I don’t see any reason to put two harmful products up against each other,” Årehed said. “It is true that smoking is more harmful than most things you can do, including snus. But that said, there are many health risks even with snus.”

“It’s difficult to say that something is as toxic for you as smoking a cigarette unless you’re starting to talk about ingesting cyanide or rat poison,” Erika Sward, assistant vice president of national advocacy for the American Lung Association told the website.

Other studies have linked snus to increased risk of heart disease, diabetes and premature births if used during pregnancy.

A June 2023 study by the Norwegian Institute of Public Health showed that the risk of throat and pancreatic cancer was three and two times greater, respectively, among frequent snus users.

But in 2017, a study in the International Journal of Cance concluded there was no link between cancer and snus.

Arehed said she fears that just like with smoking it will take years to show “to what extent these products were harmful”.

But others say it is part of the national fabric.

“It’s part of the Swedish culture, it’s like the Swedish equivalent of Italian Parma ham or any other cultural habit,” said Patrik Hildingsson, a spokesman for Swedish Match, Sweden’s top snus maker, which was acquired by tobacco giant Philip Morris last year.

He said policymakers should encourage the tobacco industry to develop less harmful alternatives to smoking such as snus and e-cigarettes.

“I mean, 1.2 billion smokers are still out there in the world. Some 100 million people smoke daily in the EU. And I think we can (only) go so far with policymaking regulations,” he said. “You will need to give the smokers other less harmful alternatives, and a range of them.”

The WHO however, noted that Sweden’s tobacco use is at more than 20 per cent of the adult population, similar to the global average, when you include snus and similar products.

“Switching from one harmful product to another is not a solution,” WHO said in an email. “Promoting a so-called ‘harm reduction approach’ to smoking is another way the tobacco industry is trying to mislead people about the inherently dangerous nature of these products.”

Snus products “still contain thousands of chemicals,” Steinberg told WebMD. “They still contain nicotine. They’re addictive, and they affect the cardiovascular system and increase the risk of cancer. They’re still tobacco products.”

With inputs from agencies