New ANDTS strategy includes nicotine products

–The strategy – in general – was unfortunately expected, but it is still disappointing that the extent of the tobacco pandemic is not yet understood, which, for example, affects all 17 UN development goals, including health equality, says Margaretha Haglund, Tobacco Facts' tobacco policy expert.

The government has submitted the bill with a renewed strategy for alcohol, drugs, doping, tobacco and nicotine and gambling (ANDTS) to the Riksdag.

The purpose of the strategy is to set goals and direction for how society's efforts regarding ANDTS issues will be implemented, coordinated and followed up during the strategy period 2021–2025.

The bill has seven long-term goals with prioritized areas of action (see fact box). This is an expansion of one goal since the previous strategy. Efforts to protect children and young people form the basis of ANDTS work and the new goal clarifies the need to protect children and young people.

But despite the government writing that children and young people are a particularly important target group in preventive work, that the reduction in tobacco use among young people has stalled, and that the vast majority start smoking in their teens, there is a lack of focus on tobacco prevention work in the ANDTS strategy.

–Tobacco is often a gateway to other drugs – if no action is taken against tobacco and the tobacco industry, you are contributing to other drug use as well, says Margaretha Haglund.

The gender equality perspective in ANDTS work

To address the unequal health in Sweden, which is also reflected in the use of ANDTS, the equality and gender perspective should permeate ANDTS work at all levels, the government writes.

In the information efforts regarding ANDTS, there is reason to highlight the environmental burden that the production of tobacco and nicotine products entails, which in turn can increase incentives to abstain from use, according to the bill. The section mentions deforestation, pollution caused by pesticides and fertilizers, contaminated water supplies and negative impacts on the health of those working on tobacco farms, as well as waste. Tobacco production is estimated to result in approximately two million tons of waste each year. 80 percent of the garbage in Swedish cities consists of cigarette butts, cigarette packets, snuff boxes and snuff boxes.

The strategy is broadened

The new ANDTS strategy is broadened to also include gambling addiction, narcotics and tobacco-free nicotine products.

People with gambling addiction often have poorer general and mental health, financial problems and risky alcohol consumption, as well as using tobacco and drugs, according to the government.

Regarding the new so-called tobacco-free nicotine products, the government writes that it is unclear what health risks they pose, but that nicotine is highly toxic and addictive, and that children and young people in particular are sensitive to the harmful effects of nicotine. The fact that nicotine products fall outside tobacco legislation is an urgent matter to address.

Margaretha Haglund is pleased that the definition of tobacco is being expanded to also apply to nicotine products.

– The new classification of tobacco products is welcome, it is a concrete proposal that is needed to close the loophole in the Tobacco Act that means that so-called tobacco-free tobacco in tobacco-free snus is not covered by the Tobacco Act, she says.

Main preventable risk factor

In Sweden, tobacco use is estimated to account for around eight percent of the total burden of disease, which is more than twice the estimated cost of alcohol and drug use, according to the bill.

According to Register data on the harmful effects of tobacco smoking , a 2014 study by the National Board of Health and Welfare, the Karolinska Institute and the then National Institute of Public Health, approximately 12,000 people die each year in Sweden from smoking. 100,000 people are treated in hospitals due to smoking-related diseases.

The figures in the previous paragraph are not mentioned in the strategy.

Under goal 6 – The number of people who die and are injured due to their own or others' use of alcohol, drugs, doping substances, tobacco and nicotine products and gambling shall be reduced – the government writes:

“Smoking and nicotine use are the main preventable risk factors for disease and premature death, and tobacco is the single most important lifestyle area to work on to prevent cancer. Nicotine is a highly toxic and addictive substance that has effects on, among other things, the heart and blood vessels and can affect the fetus during pregnancy. Therefore, it is important to continue working to reduce all use of tobacco and nicotine.”

Despite the above writing and the facts presented about the risks of tobacco use, tobacco prevention is not included as a prioritized area of ​​intervention under goal 6. The areas that will be prioritized during the strategy period are pharmaceuticals and narcotics.

– The focus of the strategy is on prevention, and specifically aimed at protecting children and young people from the harmful effects caused by tobacco and nicotine products. Through preventive work, where we work to prevent new generations from developing nicotine addiction, we can also achieve goal 6 to reduce mortality from tobacco-related diseases, writes Magnus Jonsson, who has worked on the strategy at the Ministry of Health and Welfare, in an email to the editors.

Margaretha Haglund calls for more active measures.

– Preventive measures aimed at young people have marginal effect unless the adult world – including politics – in action rejects the tobacco industry's cynical business idea: to create nicotine addiction.

– Last year – and every year since the mid-1900th century – more people died than during the Covid-19 pandemic last year. So how long will it take before, for example, the tobacco industry is banned from marketing its harmful products? Despite the tobacco convention and the fact that the Children's Convention is now law, children's health seems to be significantly less important than the tobacco industry's profit. We have decided to put an end to Covid-19 as soon as possible with all available means – why is the tobacco pandemic allowed to continue year after year? says Margaretha Haglund.

Restrict availability

Efforts to limit availability are crucial to reducing the use of tobacco and nicotine products, reducing health disparities and especially protecting children and young people, the government writes, citing an active pricing policy, regulated sales and opening hours, age limits and strictly regulated marketing as effective measures. A precautionary principle should be applied by regulating nicotine products as harmful products.

– The government knows what is needed to address the tobacco problem, so I can only think of one thing that contributes to the delay and that is the tobacco industry's influence on our decision-makers and politicians, says Margaretha Haglund, who over the years has noted many results of the industry's influence on public health policy. Everything from incorrect knowledge to hesitation to put WHO's recommendations to combat the tobacco pandemic into action.

In order to reduce access to tobacco and nicotine products, it is important that age limits are maintained, including in distance selling on the internet. The possibility of supervision in distance selling on the internet should be strengthened, according to the bill.

To support the work of implementing the ANDTS strategy, the government is considering giving the county administrative boards the task of developing and quality-assuring the work to achieve effective and equivalent alcohol and tobacco supervision throughout the country.

To achieve the goal of fewer than five percent of the population smoking by 2025, continued active tobacco prevention work is required, according to the bill.

–It is weak writing. To achieve that goal, significantly sharper measures are required than those the government recommends in the strategy, notes Margaretha Haglund.

Evaluated the strategy 2016–2020

The Public Health Agency of Sweden has evaluated the previous ANDT strategy for 2016–2020 as part of the work to develop a new strategy. Of particular interest to Tobacco Facts is the part concerning the development towards the goal of a smoke-free Sweden by 2025, which the government has supported in 2016. The agency's four conclusions were as follows:

• Daily smoking has decreased to seven percent in both sexes – but with significant differences between ages, education and income levels, and geography
• Increasing use of new tobacco-like nicotine products among young people – an observandum in continued prevention work
• Insufficient implementation in Sweden of the various measures of the Tobacco Control Convention
• Long-term and broad preventive work at several levels needs to continue

Organization to implement the strategy

The government is considering establishing an ANDTS policy forum. The purpose of the forum should be to provide a platform for dialogue on developments, commitments and the need for action between the government, relevant authorities and civil society. The forum should also provide an opportunity to anchor government policy and inform relevant authorities and organisations.

The Public Health Agency of Sweden's role as the national coordinating authority in the ANDTS area should be maintained. The current division of responsibilities between the authorities and the current coordination in the area should remain. The ANDTS strategy should be followed up annually and a comprehensive evaluation carried out.

The efforts will be managed within the authorities' existing budget frameworks. For 2021, the government has allocated SEK 95,6 million for the implementation of the strategy. The corresponding amount will be allocated annually in 2022 and 2023.

The proposal for the ANDTS strategy will be debated in the Riksdag on June 14. A decision will be made on June 15.