STOCKHOLM — Last year, only 11 percent of U.S. adults reported smoking cigarettes in the past week, half the number of a decade prior. But in Sweden, the shift away from smoking — albeit to use other tobacco products — is nearly complete. In 2015, the Swedish government set a goal of becoming "smoke-free" by 2025. The U.S. followed suit, setting a similar 10-year smoking-cessation goal in 2020, and has regulated some smokeless tobacco alternatives as having a modified risk. Sweden's unique history and regulation of alternatives to cigarettes could provide a road map for the U.S. as it faces how to regulate these burgeoning products amid competing political interests. The country is the birthplace of snus, a form of ground-up tobacco absorbed orally, and more recently nicotine pouches, which are sachets of nicotine and flavorings also absorbed orally. Sweden was granted the sole exception to the European Union's snus ban when it was admitted in 1995. Nicotine pouches are similarly widely available in Sweden, while they have been banned in some European countries like Germany and the Netherlands. The use of nicotine pouches has exploded in popularity in Sweden, especially among youth and young women, where the legal age to purchase these products is 18. The U.S., meanwhile, raised the minimum age to purchase tobacco products to 21 through a 2019 omnibus law. The Food and Drug Administration regulates nicotine products, like pouches, as tobacco products because of a 2022 omnibus law. Sweden also expanded its indoor smoking ban in 2019 to include outdoor areas of restaurants, playgrounds, public transportation stops and the entrances to buildings where smoking is banned. In the U.S., indoor smoke bans are a mix by state. Sweden's government also began regulating non-tobacco nicotine products like nicotine pouches under a 2022 law known as the Act on Tobacco Free Nicotine Products. The law restricts marketing of tobacco-free nicotine products, delegates them to the jurisdiction of the Swedish Food Agency. It later implemented a two-tier tax structure on tobacco and nicotine products. Swedish government Sweden's Riksdag, its legislative body, has largely been aligned on traditional snus, which have a long history in Swedish culture. Restricting snus in Sweden would be politically unpopular across the spectrum. But the bigger policy split emerges in how to view the regulation of newer products like nicotine pouches and e-cigarettes. "We have kind of a broad agreement that this is part of Swedish culture, and we have had policies for regulating the sale of it and the use of it," said Karin Sundin, member of the Social Democrats in parliament, of traditional snus. "But when it comes to the white products [like nicotine pouches], there is a kind of a new discussion." The legislative body is currently under the control of a conservative bloc formed by three parties — the Moderates, Christian Democrats and Liberals. The right-wing Sweden Democrats also support the block, supplying some votes, such as on the budget. The opposition is formed through an alliance of the Social Democrats, Left Party, Centre Party and Green Party. In 2018, an alliance between the Social Democrats and the Greens, with support from the Left Party, won control of the Riksdag with a one-seat margin over a four-party conservative coalition of the Moderate Party, Centre Party, Christian Democrats and Liberals. This alliance was receptive to the concept of tobacco harm reduction, which encourages smokers to use less harmful tobacco and nicotine products. "I think the main point of the Swedish approach towards tobacco nicotine products is that it would be great if a lot of people who are smoking could go straight to kale and broccoli, but in many cases, that is impossible," said Jesper Karlsson, a Moderate member of parliament. "Ensuring that there are alternatives that are less harmful, is of course, one key component." In 2022, the current right-wing bloc gained power. Taxes Last year, Sweden implemented a law lowering the tax on snus by 20 percent while raising taxes on traditional combustible cigarettes by 9 percent. The intent is to reduce demand for cigarettes. "From the perspective of my party, we are firmly behind the target to make Sweden smoke-free. And I think while our political opponents are mainly working towards more regulations, I think our policies have been directed more at shifting the tax brackets to make sure that less harmful products are cheaper, and more harmful products are more expensive," said Karlsson. "The tax difference was a physical way of trying to achieve the goal that the parliament stated," said Tobias Andersson, a member of the Sweden Democrats in parliament who chairs the Committee on Industry and Trade. Andersson said the Centre Party had proposed financing an increase in military spending by increasing taxes on tobacco, which he opposed, but that additional regulation has not been a high priority in the Riksdag. But taxing nicotine products is more complicated in the U.S., where the federal, state and in some cases local governments levy taxes on tobacco products. Congress raised the federal tax on cigarettes to $1.01 per pack through a 2009 law. State taxes vary from $0.17 per pack in Missouri to $5.35 per pack of 20 cigarettes in New York. Federal tax on snus, meanwhile, is determined by weight at $1.51 per pound, while only some states levy additional taxes on snus. Nicotine pouches are only subject to varying state taxes. Nicotine levels There is one regulatory topic with burgeoning interest across legislative blocs. "We're looking into sort of putting a cap on nicotine," said Karlsson, for products to be allowed on the market. "If you're smoking 200 cigarettes at once, you're not feeling very well and the same goes for, you know, very high levels of nicotine." Sundin pointed out that some of these products have "sky high" levels of nicotine compared to traditional Swedish brown snus. She added that while there has been a suggestion for it to be capped at the same level as the traditional snus, "I don't think that the government has put any work in this discussion ongoing." Europe at-large Sweden's neighbors have taken a different approach to how these products are marketed and sold. Norway – which is not in the EU – requires plain packaging for all tobacco and nicotine products, meaning product appearances are standardized and sold in the same color without branding. Denmark and Finland, which are EU members, require plain packaging for tobacco products but not for nicotine pouches. Still, Sweden's membership in the EU means some regulation might be outside its control. For example, marketing changes related to social media would also need to come from the EU. Sweden's 2022 law prohibits advertising nicotine pouches on television, radio or through video-sharing platforms. Such advertising is permitted with some caveats through other mediums like podcasts or some social media. "Social media is big, and that is hard, because most of the platforms are beyond reach of the Swedish regulation," said Sundin, acknowledging that regulating how social media restricts the promotion of nicotine products would need to come from the EU parliament. The EU can also implement policy changes for pouches but cannot override Sweden's snus exception. “Nicotine pouches are not regulated on EU level at all for the moment,” said Johan Nissinen, a former Sweden Democrat who was in the Riksdag from 2014-22 and was a member of the European Parliament from 2022-24. The EU is expected to revise its Tobacco Products Directive — the current broader tobacco policy — this session unless it is postponed again. "We need some common rule, because it's not sustainable," Nissinen said. This story is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.
