The data reviewed in this paper indicate that substitution of combusted tobacco products with alternative nicotine products may contribute to lower smoking rates. This is supported by the lower smoking prevalence in countries with relatively high uptake of alternatives compared to neighboring countries with lower use of these products. The findings indicate that more rapid adoption of alternative nicotine products may help reduce smoking prevalence faster than traditional tobacco control measures focused on prevention and cessation alone.
While the debate on the degree of the risk reduction of various non-combusted alternative nicotine products continues [18], it is virtually certain that none of these products is anywhere close to smoking in terms of harm. Some of the products from all three categories—snus, HTPs, and e-cigarettes—have also been reviewed by the U.S. Food & Drug Administration (FDA) and found to be “appropriate for the protection of public health [19].” While the FDA has yet to make a determination on premarket tobacco product applications for the most recent product category of nicotine pouches, the product chemistry data indicate that their risk profile is likely similar to nicotine gum, a nicotine replacement therapy that has been on the market for decades [20].
One reason why smoking prevalence has declined in the countries included in this review may be related to the fact that the younger generations are leading the transition away from cigarettes. An exception is Japan, where youth use of all tobacco products is extremely low and tobacco use initiation probably occurs at a later age [21].
Just 1% of Norwegians aged 16–24 smoked daily in 2021 [14]. In Sweden the daily smoking prevalence among 16–29-year-olds was 3% [11], while in New Zealand the daily prevalence of smoking among 14–15-year-old students reached 1.3% [22]. Similarly, past-30-day cigarette smoking among high-school students in the United States was 1.9% [23]. Conversely, the average prevalence of daily smoking among 15–16-year-old students in the 35 countries surveyed as part of the 2019 European School Survey Project on Alcohol and Other Drugs (ESPAD) was far higher at 10%, led by Bulgaria at 21.8% and followed by Croatia (19.5%), Italy (18.7%), Romania (18.4%), and Slovakia (18.3%) [24].
It is understandable that we feel uncomfortable with youth using any nicotine or tobacco, especially as declines in smoking in all these countries have been accompanied by increased use of snus or e-cigarettes. However, as Action on Smoking and Health New Zealand director Deborah Hart explained in the context of achieving low levels of smoking among youth in New Zealand: “this is the biggest fall in youth smoking rates in a decade, and it’s extremely encouraging to see young people leading the progress towards a smokefree Aotearoa [22].”
The reality is that adolescents will probably continue to engage in risky behaviors, regardless of the legal status of a given product or activity. While some 19.6% year 12 students in the United States (aged 17–19) vaped nicotine in the past 30 days in 2021, 19.5% used marijuana, 25.8% used alcohol, and 15.5% reported being drunk at least once in the past month [25]. Therefore, a more pragmatic approach may be to ensure that if teenagers engage in risky behaviors, those risks are minimized.
If current trends persist, it is likely that in countries that have reached very low levels of smoking among youth and young adults, smoking will virtually disappear in one or two generations as these cohorts reach adulthood. However, more could and should be done to reach this objective even faster and in more countries.
The UK and New Zealand prioritize vaping for smoking cessation and harm reduction [3, 4] but are more lukewarm towards other alternatives. On the other hand, while HTPs are permitted in Japan, e-cigarettes with nicotine are not allowed for sale outside the medicinal framework, and are therefore de-facto legally unavailable [26]. Snus is prohibited in all the countries reviewed in this article except Sweden and Norway. Finally, nicotine pouches, the most recent promising lower-risk alternative to cigarettes, often remain in a regulatory vacuum.
A limitation with this paper is that the prevalence rates do not allow to take into account the country based differences that prevents firm comparability between countries, also surveys conducted during the COVID pandemic could introduce some confounding.
