Scientific Gaps Undermine Tobacco and Nicotine Policy Follow‑Up

The follow‑up report on the “Assignment to the Public Health Agency of Sweden and the National Board of Health and Welfare to develop supporting material for monitoring the objective of tobacco and nicotine policy” (S2025/01796) demonstrates clear signs of institutional activism, reflected in a lack of scientific quality and methodological breadth. This response follows a recurring pattern evident in previous reporting under the earlier government assignment S2022/01825.

Failure to Deliver the Requested Policy Metrics

The most fundamental problem is that the Public Health Agency of Sweden fails to address the specific question posed by the Government. Despite the Government’s explicit request for “supporting material in the form of statistical measures to monitor the objective of tobacco and nicotine policy,” no such measures are provided. This omission makes the report’s conclusions wholly inadequate as a decision‑making basis for monitoring the Parliament’s stated objective of “reducing the medical and social harms caused by tobacco and nicotine products.”

In practice, the agency relies almost exclusively on epidemiological studies and conventional statistical indicators to estimate the relative harmfulness of different tobacco and nicotine products. There is a conspicuous absence of alternative approaches, such as toxicological risk assessments, experimental studies, or exposure‑based modeling informed by dose–response relationships. Exclusive reliance on epidemiology risks reinforcing existing knowledge gaps, particularly given that such studies are often constrained by confounding factors and long disease latency periods.

The Case of Snus and Nicotine Pouches: The Limits of Epidemiology

This is especially puzzling in the context of the agency’s assessment of the relative harm of snus and nicotine pouches compared with cigarettes. To date, more than 300 studies on the category have been published, including clinical trials and epidemiological research. A substantial majority of these epidemiological studies clearly demonstrate significantly lower risks of cardiovascular disease, respiratory disease, and cancer associated with use of snus and nicotine pouches compared with cigarette smoking. These findings are not addressed at all in the agency’s response.

Evidence‑based medicine is founded on a clear hierarchy of evidence, with randomized controlled trials and meta‑analyses at the top, while observational studies and expert opinions carry less weight. When evidence at the highest level is insufficient, accepted practice is to draw on lower‑level evidence to arrive at the most well‑informed assessment possible. One cannot, as the Public Health Agency has done, dismiss the Government’s question on the grounds that data do not exist merely because the evidence does not meet the most stringent criteria. Instead, a pragmatic approach is required, using the best available evidence to support policy decisions and recommendations.

Missed Alignment With International Practice

It is therefore highly remarkable that the report does not seriously examine or apply validated international methods for assessing relative harm, such as multi‑criteria risk matrices or expert panels based on GRADE principles. As a result, the agency misses the opportunity to triangulate evidence from multiple scientific disciplines, which could in fact have enabled a meaningful response to the Government by providing an actual assessment of relative harm.

Internationally, there are several examples of successful evaluation of the relative risks of different tobacco and nicotine products. The U.S. Food and Drug Administration (FDA), for example, applies a well‑documented risk assessment framework in which multiparametric methods, including toxicological evaluations and expert panels, play a central role (The Relative Risks of Tobacco Products | FDA).

Estimates of relative harm have also been published in peer‑reviewed scientific journals, consistently showing that snus, nicotine pouches, e‑cigarettes, and heated tobacco products are substantially less harmful than cigarette smoking (Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach | European Addiction Research | Karger Publishers Nicotine products relative risk assessment: an… | F1000Research).

Contradictions With National Health Guidelines

That the Public Health Agency ultimately concludes that it is not possible in any way to estimate the relative harmfulness of different products constitutes institutional obstruction, especially in light of the fact that the National Board of Health and Welfare, which contributed to the agency’s report, already states in its National Guidelines for Unhealty Lifestyles that the risk associated with daily use of snus and nicotine pouches among adults is substantially lower than that of daily smoking. The National Board also quantifies this risk as lower than that associated with unhealthy dietary habits or insufficient physical activity, as presented in those guidelines.

In developing the national guidelines on unhealthy lifestyles, the National Board of Health and Welfare employed a transparent and evidence‑based methodology to compare risks across different products and lifestyle factors, despite significant differences between the parameters involved. The approach is based on systematic literature searches in international databases, use of both MeSH terms and free‑text searches, evidence grading according to GRADE, compilation of health‑economic data, and prioritization using a modified Delphi method. The Global Burden of Disease (GBD) study was used to quantify the harms of various lifestyle factors by analyzing their impact on disease burden and mortality at the population level. This involved collecting and comparing data on risk factors such as smoking, use of snus and nicotine pouches, alcohol consumption, dietary habits, and physical inactivity, and estimating their relative contributions to lost healthy life years (DALYs) and deaths. The results were visualized in tables and graphs clearly showing relative harm levels and were used to assess and rank risks such as daily use of snus and nicotine pouches versus daily cigarette smoking and other unhealthy behaviors. A similar methodology could have been applied to assess the relative harmfulness of other tobacco and nicotine products, if not for the institutional obstruction exercised by the Public Health Agency’s Östersund office.

While the agency’s response to the Government acknowledges uncertainty regarding the long‑term health effects of newer nicotine products, it notably refrains from proposing any concrete research initiatives or international collaborations to address these evidence gaps. Taken together, the follow‑up report can be described as nothing less than institutional obstruction toward the Swedish Parliament, achieved through delay and inaction, in failing to deliver even a basic, scientifically grounded decision‑making framework to its commissioning authority and funder.