Joseph Hart 20 September 2023


The harm caused by nicotine products exists on a continuum. While most people understand this already, sometimes it is hard to get a true sense of scale when comparing nicotine delivery methods.

However, a systematic meta-analysis called Nicotine Products Relative Risk Assessment (Murkett, 2020) clearly shows the relationship between different nicotine-containing products.

The paper is full of interesting facts and observations. However, two graphics demonstrate just how practical both snus and nicotine pouches are, especially compared to traditional nicotine delivery products.

Let’s take a look at these graphics before discussing how they should impact thinking around nicotine product regulation.

Excess deaths of nicotine products

, The Relative Harm of Nicotine Products, The Daily Pouch
Nicotine Product Relative Risk Assessment (Murkett, 2020)

This graph helps demonstrate the differences between using Nicotine Replacement Therapy (NRT) products and more traditional nicotine delivery methods within the context of the respective lifetime risk of cancer.

At the top of the pile, we have combustible cigarettes with an excess cancer rate of 3,518 per 100,000 people. The results for snus were 2.9 excess deaths, while nicotine pouches (or, as they are referred to in the paper, Non-tobacco pouches) come in at just 0.2 excess deaths.

Relative risk of nicotine products

, The Relative Harm of Nicotine Products, The Daily Pouch
Nicotine Product Relative Risk Assessment (Murkett, 2020)

The data here uses combustible cigarettes as the benchmark and weighs the relative risk of each nicotine-containing product against these destructive items. Again, we see that snus (6) and Electronic Cigarettes (3) are far healthier options than cigarettes at 100, with “Non-tobacco pouches” again showing a low score of 0.1.

Why are these graphs important?

When it comes to the regulation of products like snus and nicotine pouches, these graphs demonstrate the absurdity of treating them like cigarettes, or in some cases, as if they are worse than cigarettes. Netherlands, Belgium, and Germany view nicotine pouches as products that pose a severe risk to public health while allowing their citizens to smoke freely.

However, the data doesn’t support this approach. In fact, it directly counters it. If public health and well-being are the goal, governments should embrace and promote healthy alternatives, not ban them and block their citizen’s pathways to better health outcomes.

What governments and regulators should take from this data?

One of the first things this data demonstrates is that combustible cigarettes are a big problem for public health. Average EU smoking rates sit at 19.7%. These numbers have been dropping steadily for years, but it’s still 1 in 5 adults. In countries like Greece, Turkey, and Bulgaria, that number is over 1 in 4.

Outright smoking bans for citizens under a certain age are being trialled in the US. For example, Brookline, Massachusetts, has taken a novel approach to tobacco control. But human history shows us that prohibition doesn’t work. Instead, it leads to unregulated black market products that are worse for human health.

Raising excise duty on cigarettes can made a difference. If you make a product unaffordable, people will have no choice but to stop. But this observations also stands for alternative nicotine products; excessive taxes will put them out of reach of people and possibly force them to engage with black market cigarettes.

Sweden’s recent move to reduce tax on snus is an example of incentivising harm reduction products. However, neighbouring Finland’s decision to regulate nicotine pouches under its tobacco law shows a grave misunderstanding of the relative risk of nicotine products and the dynamics of encouraging your population to stop smoking.

Final thoughts

The data clearly shows that some types of nicotine delivery are far safer than others. It’s no surprise to see combustible cigarettes at the top of the tree of harmful products. Snus and nicotine pouches carry much less risk. If governments are serious about driving down cancer rates in their country, they should do everything they can to encourage citizens to make the switch.