Joseph Hart 24 June 2023


If you spend any time reading about tobacco harm reduction, you’ll know the name, Professor Karl Fagerstrom.

Over a career spanning almost 50 years, he has authored more than 100 frequently-cited papers on smoking-related public health matters. He is also the inventor of the Fagerström Test for Nicotine Dependence, a well-established method for evaluating physical nicotine dependence.

Professor Fagerstrom’s career as a clinical psychologist is so accomplished it’s impossible to include it all. He is a founding member of the Society for Research on Nicotine and Tobacco and was previously a Deputy Editor of the Nicotine & Tobacco Research. His work has also garnered some significant awards, such as a World Health Organisation medal in 1999.

Even as a Professor Emeritus, he remains an active and passionate harm reduction advocate, speaking at international conferences, consulting, and lending his sensible voice to the vital battle to reduce smoking-related death and disease. 

His most recent work was a report called The Swedish Experience, alongside two other harm-reduction heavyweights, Dr Delon Human and Dr Anders Milton.

Fagerström nicotine snus, Professor Karl Fagerstrom interview, The Daily Pouch

Daily Pouch writer Richard Crosby was at a recent event in Warsaw to listen to some of the report’s authors, where fellow writer and head of Considerate Pouchers Sweden, Carissa During, joined the panel. We’ll be writing about that in more detail soon!

Fagerström nicotine snus, Professor Karl Fagerstrom interview, The Daily Pouch

The report outlines the attitudes and policy decisions that have allowed Sweden to achieve a remarkably low smoking prevalence that looks set to dip below 5% this year. That number is important because it’s the EU’s “smoke-free” target, which they hope to hit by 2040.

Fagerström nicotine snus, Professor Karl Fagerstrom interview, The Daily Pouch

One of the more perplexing aspects of the EU’s ambitious target is their reluctance to draw inspiration from a country that reached that goal way ahead of schedule. However, there is some indication that attitudes are changing, with some MEPs recently speaking with We Are Innovation.

Fagerström nicotine snus, Professor Karl Fagerstrom interview, The Daily Pouch

Professor Fagerstrom was kind enough to share his time to answer a few questions about Snus, nicotine pouches, UK tobacco harm reduction regulations, and, of course, the Swedish Experience. 

An engaging speaker with a huge depth of knowledge, his perspectives help shine a light on the often incomprehensible decisions made by governments and health bodies when it comes to tobacco control.

In light of Sweden’s success in reducing smoking to 5%, why do you think governments and health agencies have been reluctant to adopt a similar approach?

There are many factors. But the strongest and most important one is that the tobacco industry stands to benefit from the strategy used in Sweden and Norway. The tobacco industry has such a bad reputation. So, it’s very difficult for anyone to do anything that benefits the industry.

Also, in scientific papers and journals, if you find something positive that could be potentially used by the tobacco industry, you get a heavy critique from the reviewers. “We can’t say this, we can’t say that.” But, if, on the other hand, you want to bash the tobacco industry, even if the data doesn’t support it, that’s okay. So, I think there’s a hang-up there that’s tough to get around.  

In the Swedish tobacco industry, the company Swedish Match realised fairly early on that cigarettes were not the future. So they divested from cigarettes a long time ago. Anti-tobacco campaigners have been telling companies to stop selling or divest. However, when Swedish Match did this, they weren’t treated any better than other tobacco companies.

What’s more, even though people are starting to understand that nicotine may not by itself cause cancer, cardiovascular disease, or respiratory illness, it’s still categorised as dependence. And you don’t want the young ones to become dependent on anything. I think that’s a deep-rooted feeling I can sympathise with in many ways.

How have anti-tobacco campaigners changed their aims in recent years?

Many of them have retreated to arguing that it’s a drug and it’s about dependence. Now that we have tobacco-free nicotine pouches, it’s a clean drug.

It may even be positive for public health to have pure nicotine products. I don’t believe in a completely drug-free society. I’d love to live in one if it was possible, but paradise hasn’t happened yet. People have physical and psychic pain, so they will always search for ways to alter their minds and consciousness. I think nicotine is preferable compared to other drugs.   

Do you think it’s time that we rethink how we regulate nicotine?

In the Nordic countries, alcohol is a little more regulated than in the rest of Europe. The harmfulness of the product dictates the regulation. With alcohol, the strongest product has the most restrictions, taxation, and advertising constraints. That could be used for nicotine.

Today, we regulate tobacco regardless of the product’s harmfulness. However, there is a discontinuum of harm from cigarettes at the one end to a nicotine patch at the other. We should use a regulatory system similar to alcohol.

The Netherlands announced they are banning nicotine pouches. It’s really strange that they decriminalise cannabis but ban nicotine pouches.

Isn’t it? It’s the same in Germany. I’ve been to two meetings in Germany discussing this, and it’s so hard to get the politicians to understand that nicotine pouches cause very little harm. Also, Germany is legalising cannabis there now. That decision is more or less clear. 

So you have to wonder how they are answering a question from a sensible position if you’re legalising cannabis but banning pure nicotine. If anything, cigarettes should be banned. Of course, You can’t just ban them immediately, but you could phase them out.

In the UK, we have pretty sensible regulations. How do you think that happened?

The UK has Michael Russel (the late smoking harm reduction pioneer) and his students, and they have proliferated, they have been vocal, and they have done good science. The British government has actually listened to science more than other governments that haven’t been willing to listen.

Do you think that having a public healthcare system like the NHS makes it easier to argue for tobacco harm reduction?

I think it can be. Even people who are sort of puritan about tobacco or alcohol, you can maybe reach them on a logical or financial level about the benefits of vaping or nicotine pouches.

There are some pretty powerful forces campaigning against tobacco-alternative products, such as the WHO and even Michael Bloomberg. Do you think we can reach those people somehow?

I’m not particularly well informed about why Bloomberg is actually giving so much money to this, how it’s transferred, and to whom. So I can’t comment much on that. 

But what has been built up over the last ten years or so is that there are a lot of people that use support from Bloomberg to make their living. They have their salary, they are employed, and if that happens, you also have to keep the problem present. If you don’t have the issue, there’s no need for Bloomberg to give all this money.

For example, when we did prevalence studies before, we used to measure daily or regular smokers because smoking occasionally was not much of a problem for public health. But nowadays, you ask if you have used tobacco for the last week or month. So even if someone experimented with one cigarette in the last month, they get added to the prevalence rates, so you get high prevalence.

The media treats tobacco harm-reduction products with disdain. Too often, the articles are really negative. Is there anything we can do to ensure the right message gets out?

The Clive Bates group that I’m part of includes lots of active people and many very, very good scientists. There are conferences, like the one organised in Warsaw every year and other e-cigarette summits. There are activities, but it’s hard to get across to the press. There is very little to be gained for them in talking positively about nicotine.

What about the future? Do you think the EU will soften its approach to alternative tobacco products?

It will be interesting to see what the EU will do with nicotine pouches. I think the reason e-cigarettes were approved is that there were so many people using them, and there was pressure from the users themselves.

So unless we have a situation where hundreds of nicotine pouch users are outside the parliament, I don’t know if we’ll have sensible regulation. 

But the Netherlands and Belgium will probably ban nicotine pouches, and then it will take at least ten years for something to change that. And that something is probably epidemiology. So, for example, if people have been using nicotine pouches in the UK for a decade and there are enough users to detect whether or not it causes cancer or cardiovascular disease. Then it will be hard to hide any longer.

Politicians are strange. I’ve lost count of the number of health ministers who don’t know the difference between tobacco and nicotine. What’s going on there?

You’re touching on a very interesting point that I’ve been discussing a lot. Quite often, politicians say that nicotine causes cancers and cardiovascular deaths when what they actually mean is cigarettes. It’s not nicotine; it’s cigarettes. 

When they use definitions and concepts in this casual way, it misleads the public. In all sorts of articles and clinical trials, you see the word nicotine. It’s just one of 7,000 substances in cigarettes.

Do you think nicotine pouches will become a substitute for Snus in the Swedish market?

It’s happening already. About half of the people under 30 who previously used Snus have switched to nicotine pouches already. There has already been a transformation. Among older people, it will take longer. 

I should also mention women here. Traditionally, they have been reluctant to use Snus. But nicotine pouches are a much more clean, white, smaller product. They also come in more flavours than traditional Snus, so they are more appealing to that demographic.

I really believe that when you give people good choices, the overwhelming majority will make healthier decisions. Do you agree, or is it a bit more complicated than that?

I do. I even think the FDA understood that you couldn’t only work with a whip. You also need carrots to help smokers who have difficulties giving up. Steve Gottlieb, the FDA commissioner, made some good remarks that the product comes on a continuum of risk and that nicotine itself is not harmful.

What do you think has changed over the last 15 to 20 years in the smoking harm reduction space?

Not much has changed. The big changes are that the EU’s Tobacco Products Directive (TPD) has approved e-cigarettes. I also think that was a precursor to developing nicotine pouches. Before, that wouldn’t have been possible because it would have had to be classified as a medicine to go through.

But with e-cigarettes on the market, companies challenged the regulatory system, and the legal instances in some countries have found that it’s a legal product to keep on the market. That’s what happened in Sweden and other countries.