Vaxholm, Sweden — For Karl Fagerström, a now-retired Swedish researcher, the solution to quitting smoking is clear: offering safer alternatives. In 2000, he founded Niconovum, a pharmaceutical company that pioneered tobacco-free nicotine pouches, inspired by substitutes like patches and gum.
His goal was clear: to offer a more effective tool for quitting smoking. The company was subsequently sold to Reynolds American, which was itself absorbed by British American Tobacco in 2017.
While the European Union initially supported e-cigarettes as a smoking cessation aid, nicotine pouches have since become a mainstream consumer product. However, health authorities' interest in these alternatives has waned, while the tobacco industry has largely taken them over, particularly in the United States, where pouches and snus coexist on the market.
According to Fagerström, the reluctance toward harm reduction stems from a historical distrust of the tobacco industry, which bought up the small, pioneering companies in the sector. For him, banning or demonizing nicotine use, like the failures of alcohol or drug prohibition, is doomed to failure. He advocates pragmatic recognition: nicotine consumption will continue, so it might as well be channeled into less harmful forms.
The Swedish way: same consumption, fewer deaths
Patrik Hildingsson, vice president of communications at Swedish Match (a Philip Morris International group), points out that Sweden consumes as much nicotine as other countries, but prefers oral products, which reduces smoking-related deaths. "We use as much nicotine, but we don't die as much from it," he says. Smoked tobacco, the main cause of tobacco-related deaths, is severely restricted in public places.
However, some public health professionals remain cautious. They point to the industry's track record, such as the 2006 conviction of tobacco majors for misinformation about health risks. Niclas Malmberg, a former MP and member of the Tobaksfakta think tank, believes the industry changed its strategy after losing the battle over cigarettes.
Substitutes: still controversial options
For harm reduction advocates, better informing the public about these alternatives could enable a gradual shift away from traditional cigarettes. Some professionals even doubt the long-term effectiveness of nicotine gum or patches.
Snus, a culturally embedded product in Sweden, benefits from extensive scientific documentation. The more recent nicotine pouches are still understudied and often confused with snus in analyses. The Swedish public health agency, Folkhälsomyndigheten, acknowledges a statistical link between snus use and reduced smoking, but calls for more research, while also hoping to refocus prevention policies on nicotine.
Convincing individual journeys
Bengt and Daniel Wiberg, father and son ex-smokers, run Stingfree AB, a company that markets nicotine pouches that protect gums. Bengt, a former combined cigarette and snus user, quit smoking in 1991. But oral products caused oral irritation, linked to the increased pH needed for nicotine absorption. He then designed a protective device inside the pouch to reduce pain.
His son, Daniel, predicts that in a few years, American dentists will also have patients using pouches. However, the Wibergs lament the high cost of FDA approval: up to $1,5 million per product.
Towards regulatory opening?
The US market remains highly regulated, although there are signs of opening up. PMI Vice President Matt Holman, a former FDA executive, suggests Congress set performance targets for the agency to reduce approval times.
The FDA recently launched a public consultation on reduced-risk authorizations for 20 Zyn pouches. This delay has worried some U.S. lawmakers, including the Tobacco Harm Reduction Caucus, who are criticizing the agency's inaction.
But mistrust persists. Henry Waxman, a former representative, believes that promoting addictive products remains nonsense, even if they are less harmful than cigarettes.
A transition far from universal
On the ground, not everyone is convinced. Jafar Sala, a taxi driver in Stockholm, continues to smoke a pack of Winstons a day and rejects oral alternatives. He started during his military service and has no plans to change.
Despite increasing restrictions, cigarettes remain visible in Swedish cities. The path to universal tobacco harm reduction remains fraught with obstacles, including regulatory issues, historical mistrust, and diverse consumer profiles.
