GOTHENBURG, Sweden — Sweden has long made it a goal to have a smoke-free society, pushing snus and smokeless nicotine products as a safer alternative to cigarettes.
Smoking has been the leading cause of preventable death in the U.S. for decades, and its effects on public health are well documented.
But a strong tobacco and nicotine lobby, combined with gaps in data and long-term research about the safety of smokeless products, have raised questions about whether the means will truly lead to the end.
“I think that they have kind of let that drive politics in a really strong manner,” said Louise Adermark, a professor in the University of Gothenburg’s department of pharmacology, referring to Sweden’s enthusiastic embrace of snus and smokeless products. “That has also led us to this situation now where we have so many snus users, but still not knowing really the risks of the products.”
The promotion of what some view as reduced-risk tobacco and nicotine products to curb smoking comes as the U.S. has dipped its toe into authorizing similar products as having a lower health risk. Smoking is tied for an 80-year low in the U.S., and some see pushing the Swedish smokeless path as a successful route to a smokeless United States.
The global standard for a “smoke-free nation” is a country with fewer than 5 percent daily smokers. In 2024, 5.4 percent of people in Sweden smoked daily, compared to 11.6 percent of U.S. adults.
Sweden’s percentage of daily smokers drops to 4.5 percent when you discount immigrants to the country, which account for 20.8 percent of Sweden’s population. It’s a point promoted by some harm-reduction proponents who say Sweden has achieved its smoke-free goal. Public health experts discount this tactic as deceptive.
“If you find a smoker today in Sweden, it’s probably a person who came here as an immigrant,” said Niclas Malmberg, who is a board member for the think tank Tobaksfakta and a former member of the Swedish parliament. “We’re trying to get a lot of the information to those kinds of groups in the areas where they live, in the mosques they go to.”
“I don’t have a quick fix for migrant smoking, but that’s where the issue is,” said Tobias Andersson, a member of the Sweden Democrats in parliament who chairs the Committee on Industry and Trade. “I’ve never had a debate with a Swedish-born person about not quitting smoking.”
Andersson said it is harder for the government to intervene to change public behavior for immigrants in Sweden because in some cases “they’re used to not trusting the government.”
Messaging problems
Experts say the increased popularity of smokeless products has actually disguised the fact that nicotine and tobacco use in Sweden is on the rise.
Cigarettes and snus are considered tobacco products, while e-cigarettes and nicotine pouches are considered nicotine products.
Lisa L. Ermann, a tobacco prevention expert with the Cancerfonden, or Swedish Cancer Society, said that total tobacco and nicotine use in Sweden has increased from 25 percent to 28 percent over the past two years.
Surveys can underestimate how many people truly smoke regularly because people respond differently depending on whether the question is phrased as “from time to time” versus “sometimes” or “currently” versus “daily,” say some health experts.
In Sweden, the highest percentage of daily smokers is among adults over 45, but young adults aged 16-29 lead among people who smoke “occasionally,” at 9.6 percent.
Snus’ popularity as a staple among Swedish men has led to lower smoking rates in Sweden compared with other European countries. In the hours CQ Roll Call spent reporting from tobacco vendors in March, no women purchased traditional snus.
Ermann said it is a misconception that snus is a cessation product and that some evidence suggests “that snus use or e-cigarette use will increase the risk of taking up smoking over time.”
The introduction of nicotine pouches to the market shifted usage trends, with marketing and uptake higher among younger women.
Among men aged 16-84, 21.6 percent use snus daily, while 15.2 percent of women in that age group report using nicotine pouches daily.
Public health messaging
Simply put, public health messaging is hard and underfunded.
Multiple Swedish public health experts CQ Roll Call spoke with said their children use or have used nicotine pouches despite their own warnings.
At the same time, overly restrictive anti-drug campaigns can sometimes backfire and actually encourage rebel-seeking behavior among youth.
Some well-intentioned efforts like the American D.A.R.E. program and Just Say No initiatives have not been proven to be effective at curbing youth substance use. At the same time, the U.S. has scaled back staffing and support of proven prevention and cessation programs.
“If you see drops in funding provided for tobacco prevention and cessation today, we may not see that impact for another 10 to 15 years, and that is what we are very concerned about,” said Suchitra Krishnan-Sarin, vice chairperson of the American Association for Cancer Research Tobacco Products and Cancer Subcommittee and a professor at Yale University.
Magnus Lundback, a cardiologist at Danderyd Hospital and associate professor at the Karolinska Institute, said it can be difficult for the Swedish medical community to understand the nuance of when to intervene on tobacco and nicotine use.
While your doctor is likely to encourage you not to smoke, he said, it’s less likely that even in a primary care setting you’d be asked and discouraged to use snus or nicotine pouches.
As a cardiologist, he has seen how long-term snus use can lead to stiffening of the blood vessels and can make patients less responsive to heart medications like nitroglycerin.
“That’s one of the things that really is something that ties our politicians together, is the opinion that snus is good for health,” he said. “American politicians are more used to, you know, handling these kinds of lobby organizations. But Swedish politicians are not so, and … the industry can, you know, create the narrative and influence our politicians very easily.”
Lundback said an individual would typically use a medical tobacco cessation product for three to four weeks to gradually wean off of the drug, which is different from products that are promoted as a replacement for smoking without an off-ramp.
“The goal is not to become nicotine free. It’s just to use nicotine in another way,” he said. “That’s the big difference.”
He acknowledged that many of the currently available cessation products are not very efficient but that the “introduction of other nicotine products is not a very good alternative.”
“They’re not very efficient. I can tell you, if they were then this wouldn’t have been a question,” he said.
It’s also not always easy to access traditional treatment in either country.
In the U.S., all states cover at least some tobacco cessation treatments through Medicaid, but requirements vary by state on who is eligible for treatment and whether that includes covered counseling.
Sen. Lisa Blunt Rochester, D-Del., has legislation that would require Medicaid — the largest payer of substance-use treatment — to cover tobacco cessation services without cost-sharing.
There are also concerns about cuts to National Institutes of Health research on tobacco.
Benjamin Toll, director of the tobacco treatment program at the Hollings Cancer Center, said the U.S. is at a tipping point in 2025 where non-combustible nicotine products like nicotine pouches and e-cigarettes will outpace combustible products like cigarettes. But there is limited data on whether smoking cessation treatments would work for these other products.
“In clinical medicine, it’s important that you have clinical trials that show that treatments work. Currently, there’s no novel treatments,” Toll said at a congressional briefing on tobacco control on July 23. “If there’s huge cuts to NIH, it’s going to really drastically limit our ability to test novel treatments for both.”
This story is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.
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