Nicopedia listened to a talk with Karl-Olof Fagerström, a senior lecturer, licenced psychologist and internationally recognised researcher into nicotine dependence and smoking cessation.
Senior Lecturer Karl Olov Fagerström co-developed Nicorette before later founding the company Niconovum, which now markets Zonic products that help people stop smoking. We asked Karl-Olof Fagerström to summarise the conclusions of his research to Nicopedia's readers.
Damage limitation and increased safety are usually no problem if it is a case of having a smoke detector at home or having a belt on while driving, in which cases punishment rarely needs to be imposed. When it comes to forgoing the effects of intoxication from drugs, it is much more difficult to influence our behaviours, however. Even the heavy criminalisation of drug use that we have had in the Western world over the last 50 years has in no way solved the problem.
When it comes to culturally accepted and legal drugs, prohibition on alcohol, tobacco and caffeine in its various forms has proven ineffective in the Western world. The period of alcohol prohibition in the United States encouraged organised crime, while stringent regulation of alcohol has not been shown to significantly reduce alcohol use either. Even the appetite for seemingly harmless coffee, drinking of which was banned for periods during the 18th century in Sweden, could not be quashed, moving to a ‘black’ market instead. Coffee drinking is a good example of damage limitation - in the 1950s we switched from cooking the coffee, which created some unhealthy acids, to brewing coffee.
What are the damage limitation options for tobacco/nicotine products? Let's take a look at some facts first of all. The damage limitation principle is ideal for tobacco products and, in particular, smoking, as nicotine, which is the primary substance desired, itself has moderate harmful effects and only a fraction of that of smoking. This is something that the US Medicines Agency has decided to exploit in its strategy to reduce the harmfulness of tobacco smoking. The head of the Agency said the following in 2018: "nicotine, while highly addictive, is delivered through products on a continuum of risk, and that in order to address successfully cigarette addiction, we must make it possible for current adult smokers who still seek nicotine to get it from alternative and less harmful sources".
"According to the WHO's calculations, Swedish men who, unlike other men in the EU, used snus instead of smoking, have a tobacco-related mortality rate that is less than half the average for the EU."
– Karl Olof Fagerström
(550/100000 for EU and 222/100000 for Sweden). For lung cancer, other cancers and cardiovascular diseases induced by smoking, Swedish men have the lowest mortality rate out of any country. This does not apply to women who have mainly smoked and used snus to a small extent.
Sweden has by far the lowest incidence of smoking in the EU, with approx. 6% of men and approx. 8% women smoking daily. Norway comes second, with about 10% for both sexes. Norwegian men, who have increasingly begun to use snus, also have a low mortality rate with regard to tobacco-related deaths. Swedish men also have the lowest incidence of lip and mouth cancer. A large global investigation of 84 risk factors funded by Bloomberg Philatropies found there was no increased risk of ill health among users of Swedish snus.
After this has been said, however, you must not, in my opinion, regard snus and nicotine products as completely harmless. Nicotine is clearly addictive and results in difficulty quitting. In comparison to caffeine, average nicotine users are more dependent than the average consumer of caffeine, but because so many more people use caffeine, the number of people addicted to caffeine is higher in the Swedish population. Nicotine, like many other substances such as alcohol and many medications, should not be used during pregnancy as it increases the risk of various complications and can affect the fetal brain in a way that may increase the risk of self-use in adulthood. Nicotine use does not appear to increase the risk of the onset of stroke or heart attack but can make the damage greater in the event of such. The risk of the onset of type 2 diabetes in heavy consumers may also be increased by snus.
Snus also appears to have been, and is, the most common smoking cessation aid among Swedish and Norwegian men. The effect of snus as a smoking cessation aid is also markedly better than for other drug-grade agents. Perhaps because snus is used for longer than the other means, it provides better satisfaction via a stronger nicotine dose and is cheaper. In the UK, meanwhile, e-cigarettes appear to have taken on the same role as snus in Sweden and Norway. A Swedish study has estimated that if the EU had the same tobacco habits as Sweden, it would have had over 300,000 fewer deaths annually. In terms of the health benefits provided, it’s second-to-none and represents true damage limitation. Not making the most of the health benefits on this scale seems difficult to justify. Some argue, however, that we don't need nicotine or tobacco at all. Why, then, should we embrace damage limitation? As was initially stated, how realistic is it to imagine a democratic government that has great individual freedom and restrictions on punishment and use of violence would achieve this? As for people's seemingly strong appetite for even very moderately mind-altering drugs (nicotine and caffeine), one might wonder if it is just a random coincidence that cannabis is increasing in use and even being legalised, or whether it has something to do with the suppression of tobacco/nicotine.
As pointed out by some, i.e. that all tobacco and nicotine products are equally harmful or fail to provide true information about the dangers, does not reduce the level of disease and mortality that is possible, and is unethical. Interest in quitting smoking is reduced if it is perceived that snus and e-cigarettes are just as dangerous. Effective tobacco and nicotine regulation should at least involve these two points A) that the 18-year limit for purchases is strictly complied with or, if possible, increased to 21 years when the number of those starting tobacco use that occur after the age of 21 is completely negligible, and B) a regulation similar to it in the case of alcohol where products can be regulated in terms of availability, tax, advertising, etc. in view of its harmfulness.
Karl Olof Fagerström - Senior Lecturer, Expert on Tobacco and Nicotine.