UPPSALA, Sweden — For Swedish youth, it’s unavoidable. Enter nearly any restaurant or bar in Sweden, and you’ll see tables with a cluster of plastic packs of nicotine pouches, or snus, in the center. On social media, influencers tout mini-crocheted purses designed to fit a plastic canister and crystal adorned boxes. Nicotine pouches have become a Swedish social statement — as commonplace as sharing a post-meal tin of mints. “It's so normalized that it just comes up in daily conversations,” said Amalia Hamlin, 18. “They kind of made it fashionable. So, like, it's almost cool to have one because you can match it to your outfit.” “I don't think there’s, like, a pressure that you have to do it every day. But there's always, like, 'oh, you can just buy it once,’” said Milla Storskrubb, 17. But then, “it becomes something that people use daily.” Preventing and reducing youth tobacco and nicotine use is a shared global interest, with the World Health Organization calling for banning tobacco and nicotine in schools. Storskrubb and Hamlin both say they do not use nicotine products and previously attended sessions together through Hälsoäventyret, or The Health Adventure, when they were younger. The Health Adventure is an extracurricular educational center in Uppsala County that teaches local adolescents about drugs and alcohol. Despite nearly universal agreement that nicotine and tobacco products should not be available or marketed to children, it’s been difficult for governments and industry to navigate the fine line between protecting youth while not infringing on choices available to adults. It’s true that cigarette smoking has fallen out of vogue. But public health groups worry about the uptick of other products on youth while the research is still burgeoning, and in Sweden, snus and other smokeless tobacco products have become increasingly popular. While countries vary in how they collect public health data, Sweden’s public health agency, Folkhälsomyndigheten, has documented an increase in teen use of nicotine products. Among Swedish 15- and 16-year-olds, 16 percent have used snus. Twenty-five percent have tried nicotine pouches. And 38 percent had used e-cigarettes at some point. For 17-year-olds, that jumps to 29 percent for snus, 40 percent for pouches and 56 percent for e-cigarettes. By contrast, the U.S. saw a 25-year low in youth tobacco use last year. Nearly 6 percent of U.S. students surveyed used e-cigarettes and 1.8 percent used nicotine pouches within the previous 30 days, according to the National Youth Tobacco Survey of middle school and high school students. Education Many adults said it can be hard to say no to their teens because they use the products themselves. Unlike with alcohol or cigarettes, it’s not unusual for sports coaches or teachers to use them during instruction or training during the day. Swedish secondary schooling runs to age 19, and Swedish law restricts nicotine products to adults 18 and up. Ayah Altaiy’s mom smoked before she was born and quit when she became pregnant with Ayah. Her mother’s warnings and her religious beliefs drove her to not use nicotine or tobacco, said Altaiy, 19, a peer ambassador advocating children's right to a tobacco- and nicotine-free future. “I don't understand how some parents do not see the problem with it,” said Altaiy. “I have also heard from my friends that their parents buy them for them because their argument is it's better that they know instead of them going behind their back. But I would say that it's an even bigger problem if they know and they let them do it.” Seventy-two percent of Swedish teens aged 14-18 say it is easy to access nicotine pouches when you are under 18, according to a recent survey conducted by Novus for A Non Smoking Generation, a Swedish NGO. For Helen Stjerna, secretary general of A Non Smoking Generation, a Swedish anti-tobacco group, the goal is to prohibit using products in schools. Currently it varies by municipality. The U.S. also has localized rules about possessing products on campus. In Sweden, the central government proposes and writes a bill and then gives it to parliament, which can vote on it. Stjerna said advocates have sent a proposal to the prime minister about nicotine-free school hours to consider. Stjerna said that while Sweden has strong anti-tobacco laws and tobacco-free public areas, they’ve been trying to alert politicians about the need to regulate nicotine products to deter youth use. “Of course, adults are free to make their own decisions,” she said, adding that nearly all Swedish tobacco and nicotine users start before age 20, and a majority start between the ages of 13 and 16. “If we could just shut down that window, then they will never start,” Stjerna said. “The tobacco industry knows this, you know, so they do everything in their way to stop us from being successful.” In Uppsala, the Health Adventure tries to counteract mixed messaging that youth receive about emerging products. For a session in mid-March, about 30 12- and 13-year-olds gathered for a daylong session to learn about the health effects of tobacco and nicotine. Elsewhere, there’s a kids playroom and a room with various interactive elements like a giant model of a snus can and visual representation of a year’s worth of old cigarettes. Part of their programming includes writing poems, drawings and essays, some of which are put together and packaged into a book that is sent to politicians. The book allows them to hear directly from youth about their general feelings and about various health risks. Their next goal is to reach the prime minister after their next book is published, slated for September. The region of Uppsala and some municipalities have funding for this kind of endeavor, but other localities have not made a similar commitment. “In health care, we talk a lot about the costs now and the costs in the future,” said Vivianne Macdisi, regional councilor and chairperson of the Health Care Board for the region. “We as a health care system have also an obligation to minimize those costs in the future, but it's very difficult because politicians don't think about in the next 10 years. They think about here and now.” Marketing Appletini. Pineapple Rum Coconut, Ruby Chocolate, Raspberry Licorice. Lollipop. Cans of flavored nicotine line the walls of every tobaksaffär, or tobacco shop. By comparison, the U.S. has authorized a far more limited range of flavors, to the chagrin of adult users who think the safeguards overcompensate in pursuing youth prevention. But a broader slate of flavored products for the U.S. could be in the pipeline — eventually. “I think the flavors make people more interested because it's like, OK, maybe it won't be as disgusting as usual,” Storskrubb said. While Swedish law prohibits targeting youth, Rosaria Galanti, professor emerita at the department of global public health at the Karolinska Institutet, said it is clear that the design and product characteristics are meant to be “appealing to a certain segment of the population.” Social media influencers might not be actively advertising nicotine products, but pouches are a regular fixture in the background of TikToks as a prop, according to several teenagers. “Just the fact that you mix such a kind of product with other fancy products, you know, like clothes and cosmetics, makes young people very confused,” Galanti said. There is worry it can be a gateway for younger folks, and there are also unregulated health claims on similar products. Newer products do not have the same age restrictions if they do not contain nicotine, such as candy cigarettes, which are banned in some countries. It also means that restrictions on advertising don’t apply. Lewa is a Swedish brand that sells flavored nicotine pouches. But they also sell “functional pouches” which are instead filled with caffeine or minerals and promoted with health claims like boosting energy or weight loss. The container is nearly identical to nicotine pouches, and they are similarly placed under one’s lip. Since onsite March reporting, Lewa’s functional line is no longer for sale in Sweden but is marketed in other countries. “With the tobacco industry so dominant, they’re using everything,” said Carina Hesse Bolin, manager of The Health Adventure. “We are, like, always in the behind. We are so far back, so even if we try it's hard.” This report is part of a journalism fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.
