Regulation or snus: what explains the success of Sweden's anti-smoking policy?

Sweden is regularly presented as a model to follow in the fight against smoking. The good results obtained in public health are attributed by the tobacco and nicotine industry to the marketing of snus. However, an article published in the journal Tobacco prevention and cessation looks at the reasons for the success of the policy to fight smoking in Sweden, which is more linked to the implementation of coherent, ambitious and applied regulations than to the consumption of snus.[1].

Resumption of consumption, social inequalities: a picture to be qualified

Although consumption levels are low, Sweden is not a tobacco-free country, with 11% smokers still in the country, 5% of whom are daily smokers. In fact, smoking is still the cause of most preventable cancers in Sweden. As elsewhere[2], Swedish smoking is a social marker and a central determinant of health inequalities. Indeed, while the daily smoking prevalence of people with a diploma equivalent to or higher than the baccalaureate is only 3%, it reaches 11% among people who stopped at the end of compulsory schooling (up to the age of 16). Within this same population, 16% consume tobacco at least occasionally. The authors of the article also point out that Sweden is currently facing a resurgence in the consumption of tobacco and nicotine products, particularly among the younger generations.

Consistent and enforced regulations

While social disparities and the resurgence of tobacco consumption may nuance the often irenic representation of the Swedish situation, the fact remains that the country has recorded undeniable successes in the fight against smoking. Indeed, with the exception of a slight recovery in tobacco prevalence observed between 2020 and 2021, during the COVID-19 pandemic, consumption levels have been steadily decreasing since 1990, falling from 25% to 11% smokers. To achieve these results, Sweden has implemented a set of ambitious measures, having both dissuasive and normative effects. Thus, the country was one of the first to commit to smoke-free spaces and places, whether in the workplace, stadiums, bus stops, restaurants and bars or terraces. Although this tool has not been central to the anti-smoking policy, tax increases have been regularly implemented since the 1990s: from 1994 to 1997, from 2006 to 2009, from 2012 to 2015 and in 2021. As early as 1997, the ban on the sale of tobacco to people under 18 came into force. Unlike France, the country has observed a gradual improvement in the application of this protective ban over the years. Thus, if in 1999 four out of five sellers agreed to sell tobacco to minors, this proportion has fallen by 17 points in three years to reach 63%[3]In 2017, the sales ban was respected by almost three-quarters of retailers (74.6%)[4]. This development is explained in particular by a desire of the public authorities to monitor tobacco consumption and ensure that regulations are properly applied. In 1998, Sweden offered a full reimbursement of cessation aid for smokers. Finally, the ban on advertising and marketing was introduced in Sweden in 2005, the date on which the country ratified the WHO Framework Convention on Tobacco Control.

Snus: an obstacle in the fight against smoking

Snus consumption levels are not correlated with those of tobacco products, dismissing the idea of a transfer of consumption from one product to another. Indeed, while tobacco consumption has been in constant decline for over 30 years, snus consumption has stabilized at around 12% until 2021. Since then, daily consumption of this smokeless product has started to increase gradually, reaching 16% today. This rapid increase is largely explained by a sudden entry of women into the consumption of these products. In 2018, only 3% of them were daily consumers of snus, compared to 18% in 2024. In the same time interval, daily consumption of 15-year-old girls has more than tripled, from 3% to 14%. The authors of the article also point out that snus cannot be considered a smoking cessation product, as snus users are more likely to start smoking than others. Currently, snus is subject to more permissive regulation: the product is not subject to a limit on nicotine content, and benefits from advantageous taxation compared to traditional cigarettes. As a result, the authors of the article call on the public authorities to harmonize the regulations on all tobacco and nicotine products.

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[1] Ermann LL, Klefbom L. Swedish tobacco policy: Key learnings to decrease smoking and challenges that still lie ahead. Tobacco Prevention & Cessation. 2024;10(December):65. doi:10.18332/tpc/196350.

[2] CNCT, Tobacco worsens social inequalities, impoverishes countries and is an obstacle to development, 07/05/2010, (accessed 23/12/2024)

[3] Sundh M, Hagquist C. Compliance with a minimum-age law of 18 for the purchase of tobacco--the case of Sweden. Health Educ Res. 2006 Jun;21(3):378-85. doi:10.1093/her/cyl007. Epub 2006 May 4. PMID: 16675477.

[4] Feltmann K, Gripenberg J, Elgán TH. Sales of cigarettes to pseudo-underage mystery shoppers: Experiences from Stockholm County. Nordisk Alkohol Nark. 2021 Dec;38(6):573-585. doi:10.1177/14550725211003423. Epub 2021 Apr 12. PMID: 35309850; PMCID: PMC8900174.

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