Can UAE's smokers learn from 'clean tobacco' loving Sweden?

The National

14-04-2025

Sweden may have found the best alternative to traditional cigarettes - other than simply quitting. The rise in popularity of 'snus' tobacco pouches placed in the mouth are credited for falling cigarette use and lower deaths. Now, with a new UAE government regulation allowing oral nicotine pouches to be sold for the first time, the Emirates has a fresh weapon in the war on smoking. Can the Emirates, and heavy smoking nations in the Middle East, learn from Sweden's shift? Smoking rates in Sweden are a fraction of their EU counterparts, thanks in part to the use of snus among citizens. In 2018, lung cancer incidence was around 40 cases per 100,000 people in Sweden, compared with the EU average rate of 71 per 100,000 people. Sweden has a long relationship with snus, a tobacco product taken orally and placed between lip and gum for a slow nicotine release. For a decade or so, snus has been modernised and re-developed as a pure nicotine pouch. It has helped people, and women in particular, to quit cigarettes. Nicotine pouches are the electric car to the combustion engine age of tobacco smoking, and have been the driving force behind Sweden's record low cigarette use - and cancer rates. Around 12 per cent of the UAE population smokes, and around 20 per cent in the wider Middle East. Meanwhile, Sweden is well on course to become Europe's first smoke-free nation - defined by the World Health Organisation as a country with an adult smoking rate lower than 5 per cent. 'We have noticed that in Sweden we have less degree of smoke-related diseases compared to other countries and it's because we have fewer people who smoke compared to other countries,' said Dr Josef El-Achkar, a specialist in internal medicine and cardiology in Stockholm, Sweden. 'But the nicotine usage is not a big difference, it's how they take the nicotine. The inhalation and cigarette smoking seems to be the reason for why people get diseases, not the nicotine itself. There's also fewer cases of chronic obstructive pulmonary disease as a result of less smoking.' In 2018, lung cancer incidence was around 40 cases per 100,000 people in Sweden, compared with 113 in Hungary and an EU average rate of 71 per 100,000 people. With few nations regulating nicotine pouches to allow them on sale beyond duty-free airports, millions of smokers have been deprived of a less harmful alternative to cigarettes. Zyn - nicotine pouches developed and produced by Swedish Match - are available outside duty-free stores in only a few countries, including the US, UK, Switzerland, Hungary, South Africa, Finland, Poland, Serbia and Pakistan. In 2022, Philip Morris International, makers of Marlboro cigarettes, pushed through a $16 billion takeover of Swedish Match, to expand the company's global smoke-free agenda. The burning of tobacco creates the cancer-causing properties of conventional cigarettes. While nicotine is not entirely risk-free, smokeless products that perform in a similar way to nicotine patches will soon become more widely available. Some pouch users have experienced changes to gum infrastructure and oral health after long-term use, and nicotine itself is highly addictive. Sweden has slashed smoking rates and transitioned towards harm-reduction public health policy on tobacco. However, the country is one of the few nations with more female smokers (6.8 per cent), than males (5.9 per cent) - largely due to the popularity of snus with men. In 20th century industrial workplaces, snus was a familiar stimulant taken by male workers. Rolled up, clay-like balls of tobacco were tucked under the gum, allowing manual workers to free up their hands for labour, while continuing to take their daily nicotine habit. Patrik Strömer, secretary general of the Swedish Snus Manufacturers Association - an organisation that unites producers of snus and nicotine pouches, estimates there are some 1.2 million users in Sweden's population of almost 11 million. 'I think everybody has some kind of relation to snus,' he said. 'When the nicotine pouch entered the market 10 years ago, it was seen with both curiosity and scepticism. In the old-school tobacco users, they wanted to have the real stuff, but at the same time something that was seen as more fresh and contained no brown, wet tobacco.' The industry began to self-regulate products as they came on to the market. That included age limits, health warnings, restricted marketing and industry standards around the use of different kinds of substances. When Sweden's tobacco law came into force in July 2019, a smoking ban was enforced on outdoor restaurants and railway stations, further boosting the popularity of smokeless alternatives, particularly among women. 'Prior to that it was not seen as OK if a woman used nicotine pouches, so many smoked instead - it was a cultural thing,' Mr Strömer told The National. 'The traditional product was a cheap enjoyment for hardworking people. But you have to mould the tobacco and it is not very aesthetic or attractive, and it stains your fingers, so it was not very popular with woman at all. 'When Sweden joined the European Union, it was the only country where women smoked more than men. When you try to explain this rapid reduction in smoking prevalence among Swedish men, the answer is obvious. "When this new pouch entered the market, suddenly something became much more convenient, practical and discreet. From a sociological point of view, we have seen the effects. Now we have two smoke-free generations in Sweden, people aged 15 to 29 and 30 to 44.' Switching towards less harmful nicotine products has cut the number of Swedish-born adult smokers to 4.5 per cent - below the WHO-defined 5 per cent smoke-free threshold. That has contributed to 41 per cent fewer cancers cases than the European average, and 44 per cent fewer tobacco-related deaths. Despite those figures, introducing nicotine pouches in other nations with high smoking levels may not be a global panacea. In 2020, 22.3 per cent of the world's population used tobacco: 36.7 per cent of men and 7.8 per cent of women, and few nations have the same historic links to snus as Sweden, making the transition towards pouches a considerable challenge. Since December 2024, Sweden has enshrined tobacco harm reduction in public health policy, placing it at the vanguard of smoke-free ambition, and introduced a cap on nicotine levels in smokeless products. Limiting the strength of products helps regulate the market, experts say. Samuel Lundell, chairman of the National Association of Snus Users, said Sweden's history of smokeless tobacco has helped increase the wider adoption of nicotine pouches in the country. 'We have been using the products for hundreds of years, so we know a lot about what harm they do and the supporting research,' he said. 'Government agencies inform, but they don't always come from a harm-reduction perspective. 'That's where we have to really emphasise the huge difference you have in the health effects compared with cigarettes. On one hand you have a deadly product and then you have one which isn't deadly, so it should be an easy choice.' Social media links to the potential biohacking properties of nicotine, to improve attention or stimulation, are not scientifically proven but have fuelled a rise in use among young people, particularly in the US. That has reinforced calls for strong enforcement against underage sales. In Sweden, under-18s cannot legally buy snus or nicotine pouches. Potential links with cancer have also been scientifically debunked. A study of 400,000 male snus users by the Karolinska Institute in Stockholm found no association with a greater risk for pancreatic cancer, adding to claims oral nicotine is safer than smoking. 'The more time passes, the more of the old misconceptions we can throw away,' said Mr Lundell. 'I think it's possible to have a similar impact in the Middle East, at least if not in the absolute short term, but in a few years, absolutely. 'For young people, it's about accessing the information already out there. We already have the research, but we need to to get it across to people and that can become a bit tricky. 'A ban might be one of the worst public health decisions that could ever happen in a Middle Eastern country. Once a product has been banned, it's extremely hard to remove it. 'Meanwhile, we see millions of Europeans have lost their lives, it would be awful to see the same mistake elsewhere when there is an alternative.' * A visit to Sweden was facilitated by Philip Morris International