Report on Sweden’s Tobacco Harm Reduction Strategy and its Alignment with Sustainable Development Goals

Introduction: A Case Study in Public Health and SDG 3

Sweden’s national strategy to achieve a “smoke-free” society, defined as having fewer than 5% daily smokers, presents a complex case study in public health policy. The approach, which involves the promotion of snus and other smokeless nicotine products as alternatives to combustible cigarettes, is central to the debate on achieving Sustainable Development Goal 3 (Good Health and Well-being). While Sweden is approaching the smoke-free threshold with a daily smoking rate of 5.4%, this report examines the multifaceted implications of its strategy, including rising overall nicotine use, health equity concerns, and the long-term risks, which challenge a straightforward assessment of its success in promoting well-being.

Analysis of Progress Towards SDG 3: Good Health and Well-being

Target 3.4: Reducing Premature Mortality from Non-Communicable Diseases (NCDs)

Sweden’s harm reduction model is predicated on reducing the severe health impacts of smoking, the leading cause of preventable death and NCDs. However, experts raise significant concerns about the long-term health consequences of the alternative products being promoted.

• Uncertain Risks: Louise Adermark, a professor at the University of Gothenburg, notes that politics has been driven by the enthusiastic embrace of smokeless products, leading to a situation with many users but insufficient knowledge about the products’ long-term risks.
• Cardiovascular Impact: Dr. Magnus Lundback, a cardiologist, has observed that long-term snus use can lead to the stiffening of blood vessels and may reduce the effectiveness of certain heart medications, directly impacting cardiovascular health.
• Rising Nicotine Use: Despite lower smoking rates, total tobacco and nicotine use in Sweden has increased from 25% to 28% in the last two years. This suggests a shift in addiction rather than a net reduction, complicating the goal of preventing NCDs. Lisa L. Ermann of the Swedish Cancer Society highlights the misconception that snus is a cessation product, with some evidence suggesting it may increase the risk of future smoking.

Challenges to SDG 10: Reduced Inequalities

Target 10.2: Promoting Social Inclusion and Health Equity

The Swedish data reveals significant health disparities among different population groups, indicating a failure to ensure equitable health outcomes for all, a core tenet of SDG 10.

Demographic Disparities in Tobacco Use

1. Immigrant Populations: Public health experts and politicians acknowledge that smoking rates are disproportionately higher among immigrant communities. Niclas Malmberg, a board member for Tobaksfakta, states, “If you find a smoker today in Sweden, it’s probably a person who came here as an immigrant.” Efforts to deliver effective public health messaging to these groups face cultural and trust-related barriers.
2. Gender-Specific Trends: Usage patterns differ starkly by gender. While traditional snus remains popular among men (21.6% daily use), the introduction of new nicotine pouches has driven uptake primarily among younger women (15.2% daily use). This highlights the need for gender-sensitive health policies.

Policy, Partnerships, and Implementation Challenges (SDG 17)

The Influence of Public-Private Dynamics

The effectiveness of Sweden’s public health strategy is heavily influenced by the dynamic between government, civil society, and private industry, reflecting the complexities of SDG 17 (Partnerships for the Goals).

• Industry Lobbying: Dr. Lundback asserts that the tobacco and nicotine industry has been highly effective at creating a narrative that influences politicians, who may not be as accustomed to handling powerful lobby organizations as their American counterparts.
• Underfunded Public Health: Public health messaging and prevention programs are described as underfunded and facing significant challenges in countering industry marketing, particularly among youth.
• Gaps in Cessation and Research: The report notes parallels in the U.S., where access to proven tobacco cessation treatments through programs like Medicaid is inconsistent. Furthermore, experts like Benjamin Toll from the Hollings Cancer Center express concern over potential cuts to NIH research, which would limit the ability to develop and test effective treatments for both combustible and non-combustible nicotine products, undermining the evidence-based approach required to achieve global health goals.

SDGs Addressed in the Article

• SDG 3: Good Health and Well-being

  The article’s primary focus is on public health, specifically the strategies to reduce smoking and the health risks associated with tobacco and nicotine products. It discusses smoking as a “leading cause of preventable death,” the health effects of smokeless alternatives like snus (“stiffening of the blood vessels”), and the challenges in public health messaging and cessation programs. This directly aligns with promoting well-being and addressing major health risks.

• SDG 10: Reduced Inequalities

  The article explicitly highlights disparities in smoking rates based on origin. It notes that the smoking rate in Sweden is significantly higher among immigrants and that public health messaging struggles to reach these groups. The text states, “If you find a smoker today in Sweden, it’s probably a person who came here as an immigrant,” and points out the difficulty for the government to “intervene to change public behavior for immigrants in Sweden.” This addresses the goal of reducing inequalities within a country.

Specific Targets Identified

1. SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.

     The article connects directly to this target by discussing smoking as the “leading cause of preventable death” and a primary cause of non-communicable diseases. The entire debate around Sweden’s strategy of promoting snus is framed as a “reduced-risk” approach to prevent smoking-related mortality. Furthermore, the mention of long-term snus use leading to “stiffening of the blood vessels” highlights the ongoing concern with non-communicable diseases even with alternative products.

   • Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.

     This target is relevant as the article discusses nicotine addiction and the challenges of cessation. It questions whether promoting smokeless products is an effective cessation strategy or simply shifts the addiction, noting, “The goal is not to become nicotine free. It’s just to use nicotine in another way.” It also mentions the ineffectiveness of some youth substance use prevention programs (like D.A.R.E.) and the need for funding for proven prevention and cessation programs.

   • Target 3.a: Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate.

     The article is a case study on national tobacco control policies. It compares Sweden’s harm-reduction strategy with the situation in the U.S. and references the global standard for a “smoke-free nation” (fewer than 5% daily smokers). The discussion about the influence of the “tobacco and nicotine lobby” on politics is a key challenge in implementing the FCTC, which calls for protecting health policies from commercial and other vested interests of the tobacco industry.

2. SDG 10: Reduced Inequalities

   • Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.

     The article identifies a clear inequality in health outcomes and behaviors between the native-born Swedish population and immigrants. It states that Sweden’s smoke-free status is only achieved when “you discount immigrants” and that specific outreach efforts are being made to target these groups “in the areas where they live, in the mosques they go to.” This points to a lack of social inclusion for immigrants in the country’s public health gains and messaging.

Indicators Mentioned or Implied

1. For Target 3.4 (Reduce mortality from NCDs) & 3.a (Implement FCTC)

   • Prevalence of daily smoking: The article provides specific figures, stating that “5.4 percent of people in Sweden smoked daily, compared to 11.6 percent of U.S. adults.” This is a direct indicator of progress towards tobacco control.
   • Prevalence of occasional smoking: The article notes that young adults aged 16-29 lead among people who smoke “occasionally,” at 9.6 percent, indicating a specific area of concern for prevention.
   • Mortality from a specific risk factor: The article qualitatively identifies smoking as the “leading cause of preventable death,” which is an indicator of the mortality burden from non-communicable diseases.

2. For Target 3.5 (Prevention and treatment of substance abuse)

   • Prevalence of total nicotine and tobacco use: The article indicates that “total tobacco and nicotine use in Sweden has increased from 25 percent to 28 percent over the past two years,” suggesting that while smoking may be down, overall substance use is rising.
   • Prevalence of smokeless tobacco/nicotine use by gender: Specific data is provided as an indicator of usage trends: “21.6 percent [of men] use snus daily, while 15.2 percent of women in that age group report using nicotine pouches daily.”

3. For Target 10.2 (Promote inclusion and reduce inequalities)

   • Disaggregated data on smoking prevalence: The article implies this indicator by stating that the percentage of daily smokers in Sweden drops from 5.4% to 4.5% when immigrants are excluded. This difference in prevalence between population groups is a direct indicator of inequality in health behavior.

Summary of SDGs, Targets, and Indicators

Source: inkl.com