Can vaping stop smoking in the world?

Karl Erik Lund lit up his first cigarette during a gathering not long after Norway's smoking rates peaked. Nearly 50% of adults in the nation were smokers in the middle of the 1970s. Lund, who is now 60 years old, was youthful and never developed a serious smoking habit. But in 1986, he saw an advertisement in Oslo for a research position at the government organization that compiled cigarette data. He needed the cash, but he quickly developed a dependence on the data. "I wanted to know why people persist in engaging in behavior that defies social norms. He states, "

One of the most sophisticated anti-smoking campaigns in the world was aimed at smokers in Norway and the neighboring country of Sweden. All tobacco advertising was outlawed in Norway in 1975, and cigarette packets now contain health warnings. It became one of the most costly nations to purchase cigarettes in the 1980s as a result of increasing taxation. Children were urged to plead with their parents to stop working. Bans were implemented in offices and on public transportation. In one anti-smoking TV commercial, Dracula bit into a teenage smoker's throat before coughing and stumbling away in a black cloud.

From his country home outside of Oslo, where he is recovering from a dog-walking accident, Lund tells me that the goal of Norwegian tobacco policy was to create a society that was nicotine-free. Norway's goal was to intimidate, tax, and educate people into giving up. However, there was a problem—it wasn't functioning. By 1990, smoking rates had barely decreased to roughly 38%.

In 2004, smoking was outlawed in all public places, including pubs and restaurants, as a result of years of restrictions on indoor smoking. After Ireland, the nation was the second to enact such a restriction. Greetings from Norway. Salmon is the only thing we smoke here, according to a billboard from the health ministry at the time.

But it's too chilly to smoke outside in Norway. When smoking was outlawed, many had already started switching to snus as a substitute. Snus is an oral snuff that has a long history in Scandinavia (it rhymes with "moose"). Inhaling nicotine through the mouth instead of the lungs, users insert wet tobacco under the upper lip. Norway and Sweden had favored snus during the 19th century, while smoking became increasingly popular elsewhere in the world. However, cigarettes began to gain popularity there from the 1920s, and by the late 1960s, when snus consumption was at its lowest, it had become a relic—something your grandfather did.

Manufacturers, however, had sparked a revival in snus starting in the 1970s by creating new packaging and introducing new flavors. By that time, the loose tobacco that the older generation had been using had been neatly packaged into teabag-like pouches and marketed in vibrant tiny tins.

Snus was getting cooler, cleaner, and more practical. Sweden asked Brussels to exclude it from an EU snus prohibition in 1994 when the nation held a vote on membership. Lund recounts that bar owners, concerned about their bottom lines as Norway's 2004 smoking ban drew near (Norway is not an EU member), collaborated with snus producers to install vending machines.

The emergence of snus was worrying for a nation that had made it a goal to cleanse society of nicotine. There were worries that the influence of marketing and a fresh cachet might entice young people who did not smoke into addiction, reversing decades of cautious but steady advancement. Snus addicts have been cautioned that their habit may cause pancreatic and oral cancer.

Lund, though, saw something else. Smoking rates began a quicker decrease in the decade after the indoor smoking ban while snus consumption quadrupled. Snus consumption surpassed smoking in Norway in 2017. In comparison to the EU average of 28%, Norway and Sweden currently have among of the lowest adult smoking rates in Europe at just 12% and 10%, respectively. Sweden has some of the lowest lung cancer incidence rates in the world.

Snus in Norway has been the subject of frequent and heated controversy, which portended a larger dispute with the introduction of an e-cigarette as a substitute for traditional cigarettes. Many scientists, including Lund, would be pitted against conventional wisdom in public health. Questions that appeared to be straightforward were at its core. Could a substitute for nicotine that is available on the open market save millions of lives and put an end to smoking for good? Were smokers turning to the exact substance that the world had come to despise as their own answer to a fatal problem?

Lund has no doubts about the promise of tobacco that doesn't burn. He traveled from Oslo to London's Royal Society in November of last year for the sixth UK E-Cigarette Summit. "It is tough for us in tobacco control to grasp and accept that snus and e-cigarettes may have greater potential to make smoking obsolete than the restrictions we have spent a career working for," he said to the audience after presenting on Sweden and Norway's connections with nicotine.

Deborah Arnott recalls attending the unveiling of an interesting new technology at a casino close to Leicester Square in London. Less than a year has passed since England had enacted its indoor smoking ban in February 2008. Arnott, a key member in the UK's tobacco control movement, has served as the charity Action on Smoking and Health's (ASH) chief executive since 2003. The invitation stated, "Conference Presents Scientific Breakthrough for Much Safer Smoking." The gathering was organized by a business called SuperSmoker, whose director, the businessman from Belgium named Dimitri Kyriakopoulos, sat next to medical professionals and someone who Arnott recalls as a little celebrity (it was the chef Antony Worrall Thompson, who was then a heavy smoker).

The SuperSmoker gadget included a white shaft, an orange mouthpiece, and even a "burning" tip, making it resemble a long cigarette. But the tip had an LED light that flashed when the battery was low or shone with each puff. When the user engaged an element while inhaling, the liquid nicotine inside the cartridges transformed into vapour. Food additives simulated tobacco flavor. Cartridges were £7.95 for six and the gadget was £79. Arnott wasn't impressed.

One of the first electronic cigarettes to reach the UK market was the SuperSmoker. Smokers, like Arnott, were first doubtful. Drinkers were "stunned by what in one short year has become a horrifying sight" saw writer Terri Judd puff on a SuperSmoker at a London bar shortly after the launch event in 2008, she reported in the Independent. "One man takes out his phone and snaps a photo."

Judd came to the conclusion that it would take some time before e-cigarettes attracted "skeptical, rebellious smokers" from the cold. He recalled smoking in a bar with a friend on the eve of the UK ban, like "mourners at a wake, savoring our memories of better days," and concluded that this was the case.

A huge cloud began forming over an exhibition area at the ExCel center in east London in April of last year, ten years after the SuperSmoker's introduction. More than 100 merchants were displaying their goods below it amid a flurry of music and strobe lighting. A 20-year-old Stockport resident named Charlie Rabone was blowing vapor rings at a vape juice vendor's booth. An Italian manufacturer was offering £300 boxes for e-cigarettes, hand-carved in spalted beech wood. "Juice," as devotees refer to the liquid, is a combination of additives vegetable glycerin and propylene glycol, as well as nicotine and flavorings.

This was the fourth annual Vape Jam UK. The e-cigarette had rapidly evolved after receiving a muted response. What was first intended to be a practical tool that resembled and operated like a cigarette has evolved into something quite else. Small enterprises have created a cottage economy that fueled a $12 billion worldwide market. Vape Jam resembled a hybrid of a rock concert, culinary festival, and tech expo.

Manufacturers immediately shifted away from so-called "cigalike" devices to provide a bewildering array of options. The most modern e-cigarettes are small, looking like memory sticks or pens, while larger devices, called "mods," contain replaceable parts and produce huge clouds of smoke. The Pantone chart offers more flavor options than color options. Many of the Vape Jam participants had taken up vaping as a way of life and culture. However, the goods shown there find their way to the gas station counters and the vape shops that are springing up on high streets all around Britain.

In 2012, ASH began keeping track of e-cigarette usage, by which time 700,000 persons in the UK had already reported vaping. By 2013, that figure had almost doubled, and 3.2 million people were affected. The e-cigarette was a brand-new product, unlike snus in Scandinavia. Vaping concerned some stewards of public health in the same way as snus did, but Lund notes that "they are both grassroots and consumer-driven, and have occurred without the help of the government." They believed that this was an out-of-control product of the free market that would encourage addiction and appeal to children, maybe serving as a new entry point for cigarette use.

In contrast, the large tobacco corporations quickly started making investments in this emerging threat to their business models, marching into a market intended to reverse a health crisis they had caused. The tobacco business has previously been seen as "the excellent adversary we can all agree to detest," according to Lund. According to Arnott, there have historically been three goals for tobacco control. "And they used to all line up very well. One was to stop smoking's negative effects. A second was quitting addiction. The tobacco business was being destroyed by three.

The EU didn't take similar action against e-cigarettes as it did against snus, which it outlawed in 1992. However, the EU Tobacco Products Directive, which went into effect in 2016, banned television advertising and introduced new guidelines for liquids and equipment. It demanded that more be done to discourage young vapers and urged for new health warnings about nicotine addiction to be included to packaging. 2015 saw the end of sales to those under 18 in Britain. Other nations, such as Australia and Canada, have adopted a far tougher stance. Many countries, including Argentina, Brazil, Singapore, and the United Arab Emirates, have outright bans on e-cigarettes.

Reminders of the unknowable long-term health dangers of breathing vapour appeared, and the public's impression that vaping was not significantly safer than smoking grew. Two routine polls conducted in the US between 2012 and 2017 revealed significant increases in the percentage of people who believed e-cigarettes were just as deadly as cigarettes, if not more so. In Britain, it is allowed to vape indoors, but most companies restrict it, forcing vapers to share sidewalks with smokers.

Senior public health authorities, however, have a different perspective. According to a Public Health England report from 2015, vaping is 95% less dangerous than smoking. E-cigarettes were dubbed "the biggest health gain since vaccinations" by David Nutt, a professor of neuropsychopharmacology at Imperial College London and a former drug adviser to the UK government, in 2014. Millions of preventable deaths in Britain might be avoided if smokers converted to e-cigarettes, according to Professor John Britton, chair of the Royal College of Physicians' Tobacco Advisory Group, who called this possibility "a gigantic potential public health prize" a year prior.

When Ian Blandamer was around 14 years old, he began smoking. I didn't want to be left out since all of my friends were doing it, he claims. The now 54-year-old Blandamer grew up in Leicester and recalls watching his father smoke up to 80 cigarettes every day. When he was 16 years old, Blandamer would spend his £1 lunch money on cigarettes and chips, eventually building up to a 40-a-day smoking habit that lasted 37 years.

Blandamer began being more active after he turned 50. His doctor advised him to give up smoking as well. The most shocking moment, in his words, was when he asked his mother what she wanted for her 80th birthday and she replied that she wanted him to stop smoking. "She almost killed me when I just informed her about the meal money."

Blandamer's coworker knew about quitting, so they went out for drinks together. The well-known pharmaceutical company GlaxoSmithKline employed Mark Dickinson. He had been in charge of the 1998 European launch of the NiQuitin line of nicotine gums and patches. Dickinson has recently started his own health consulting in November 2016. He was starting to collaborate with businesses in the vaping sector. He took Blandamer to a vape store after a drink close to Dickinson's home in south-west London. Blandamer experimented with a Chinese-made Innokin T18 gadget and added some fluids with a fruit juice flavor.

This is bloody great, I thought, said Blandamer. He continued to vape outside of a coffee shop with Dickinson, who does not smoke. After quitting that day, Blandamer hasn't lighted since. I placed the remaining 15 cigarettes in a packet that I had in my shed, he claims.

Before the e-cigarette, smokers had fewer options. Tobacco firms sought and failed to develop less lethal cigarettes in the 1950s and 1960s, an endeavour that would further destroy public confidence in them. These research and reports in the 1950s and 1960s verified the link to cancer and forced governments to take action.

Sweden offered a substitute. A military physician named Claes Lundgren had observed that submariners, who were prohibited from smoking due to the risk of fire, were adopting traditional substitutes like snus in 1967. He wrote to his buddy Ove Fernö at AB Leo, a Swedish pharmaceutical business, asking whether there could be a better option. Fernö began experimenting with nicotine in chewing gum. He was prepared to introduce his gum by 1978. A term, based on the words "nicotine" and the Norwegian word for "right," "rette," had already been proposed by Lundgren.

A new stage in tobacco control was introduced with Nicorette. Pharmaceutical firms created prescription or over-the-counter medicines as a component of what became known as nicotine replacement treatment. In addition to lozenges, inhalers, and nasal sprays, nicotine patches were added to the medical cabinet in the UK in 1992 after being granted a patent in the US in 1986. Later came prescription medications meant to lessen nicotine cravings.

The acceptance of smoking addiction as a medical problem is a prerequisite for medical remedies. Blandamer by no means did. Additionally, he found smoking to be a calming and frequently sociable pastime. Patches only provided him with nicotine. The hand-to-mouth habit alone can be quite strong, in addition to a pharmaceutical addiction. Robert West, professor of health psychology and director of tobacco research at University College London, claims that this is one of nicotine's cunning methods of action. "It creates the drive to perform what you're doing and pharmacologically connects your behaviors to circumstances."

According to West, this might help to explain why many smokers seem to find success with vaping. But it's not quite that easy. Despite the inhaler's imitation of smoking motions, studies conducted before the invention of e-cigarettes in which smokers were given patches or a pharmaceutical nicotine inhaler revealed no enhanced effect in the inhaler group.

But according to recent studies, vaping is a better assistance to quitting. In one study, conducted by Peter Hajek, head of the Queen Mary University of London's Tobacco Dependence Research Unit at the Wolfson Institute of Preventive Medicine, it was shown that e-cigarettes were nearly twice as successful as nicotine replacement therapies like patches. A year after the study's beginning, 18% of the e-cigarette group had stopped smoking, compared to 10% of the nicotine replacement group. The results were published earlier this year in the New England Journal of Medicine.

Another research evaluated the effectiveness of several assistance in helping people stop. Smokers were 34% more likely to succeed in quitting smoking if they were given gum, patches, or lozenges together with motivational assistance. The likelihood of quitting was the same for those who purchased patches or gum off the shelf. People who were given an anti-craving medication were 82% more likely to cease. About 95% more smokers in the e-cigarette group were likely to give up. It is significant that e-cigarettes proved to be equally successful for smokers of various ages and social backgrounds, according to Jamie Brown, who led the research team.

More than fulfilling any urges or habits, West attributes the relative success of the e-cigarette to a single, straightforward element: the effectiveness with which it delivers nicotine to the body. "I believe that there is likely a tipping point in the pace of nicotine delivery that transforms a product from something that just stops withdrawal symptoms to something that offers you positive reinforcement and keeps you using it," he adds. In a recent research by Hajek, this impact is evident. After a year, 80% of the smokers who had quit using e-cigarettes continued to vape, compared to just 9% of those who had quit using nicotine replacement therapy.

Due to the effectiveness of vaping, many former smokers are lowering the nicotine content of their liquids. According to YouGov's most recent polls for ASH, 43% of vapers have gradually decreased the amount of nicotine they use. I ran with a few vapers at Vape Jam who had completely stopped using nicotine. They had begun in an effort to stop smoking and reduced their nicotine intake when their desires subsided. But they continued to like vaping.

Juul Labs, a Californian business, introduced a brand-new e-cigarette in 2015. Despite age restrictions on sales, it quickly gained a following among youths and was compact and stylish, looking like a USB flash drive. The epidemic of "Juuling" in high schools was reported last year. The business was accused of focusing on a new generation of non-smokers for whom vaping may serve as a gateway to smokes by promoting its brand on social media.

Parents were particularly concerned about the e-liquids' possible long-term health concerns and Juul's high nicotine level, which was almost three times the EU limit yet legal in the US. Parents stated that although vaping may be healthier for their children than smoking, there was still doubt regarding its impacts on health. In addition, Juuling was more difficult to detect. Numerous investigations were started by the Food and Drug Administration (FDA). The number of high school students who reported vaping in the previous 30 days increased, according to two surveys, one by the Centers for Disease Control and Prevention in 2019 and the other by researchers at the University of Michigan's Institute for Social Research in 2018. According to the Michigan poll, more over 25% of high school students are vaping.

The answer came quickly. This year, US states are lining up to raise the legal age to purchase tobacco products and e-cigarettes from 18 to 21, and there are proposals for a federal restriction. The FDA commanded producers to reduce the variety of flavors they offered and take further steps to stop sales to minors.

Juul Labs' headquarters, San Francisco, has issued a prohibition on the sale of e-cigarettes starting in 2019 "until the FDA conducts due diligence about Big Tobacco businesses like Juul marketing to our young." Juul claims it is concerned that the change may encourage smokers who have successfully transitioned to vaping to go back to smoking. According to the company's representative, Ted Kwong, "We have already taken the most aggressive efforts in the business to keep our goods out of the hands of people underage and are taking steps to do more."

Additionally, press stories have cautioned that e-cigarettes may result in "popcorn lung," a disease that may call for a transplant. There have been no reported cases of popcorn lung in e-cigarette users, and diacetyl is no longer permitted in e-juice sold in the EU. Popcorn lung was first noticed among workers in a popcorn factory who had been exposed to very high levels of a flavoring called diacetyl, which is also used, in small doses, in some flavors of e-liquids (and is not an ingredient in Juul). Concerns about passive vaping have been heightened by studies that have cautioned against the formaldehyde, a possible carcinogen, being present in vapour clouds.

But according to UK health organizations, there is no comparison to cigarette use. However, they have come under fire for promoting e-cigarettes as successful cessation aids. An uproar ensued when Public Health England stated in 2015 that vaping was 95% less dangerous than smoking. The data on the long-term impacts of vaping, according to editorials in the Lancet and BMJ, does not go back far enough and is not sufficiently substantial to warrant such a dramatic claim. In the lack of more convincing evidence of their safety and usefulness as cessation aids, the World Health Organization urged for tougher regulation of e-cigarettes in 2016. The safety of e-cigarettes and their efficacy as a smoking cessation aid are topics that have "evidence gaps," according to an editorial published this year in the journal Nature. It stated that "it appears premature to vigorously promote for the use of e-cigarettes, and important that regulators adopt guidelines to minimize vaping by teens" until more is known.

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, claims that when comparing the national situation to the global one, "England is a total anomaly." McKee is the most well-known vape skeptic among UK academics (several of whom have called McKee "isolated," a claim he vehemently refutes). McKee emphasizes the absence of long-term safety research as well. He acknowledges that vaping is safer than smoking, but this does not warrant its promotion until we have more information. He claims his own position has led to criticism and even death threats, and he deems the 95% statistic "untenable."

Martin Dockrell, the head of research and policy at ASH who now leads Public Health England's Tobacco Control Programme, defends the "95 percent" study and expressed astonishment at the response to it. In order to ascertain the long-term impacts of vaping, he concurs that additional study is required. His main concern was the impact that media coverage of the potential risks of vaping would have on smokers considering quitting. According to him, "year after year, we witnessed an increase in the number of people who thought vaping was at least as dangerous as smoking." Why would they change? We sought to restore the balance.

Only 17% of British people surveyed in 2018 by ASH believed vaping to be significantly less dangerous than smoking. 37% of smokers said they had never used a vape pen. They frequently cited a reluctance to switch one addiction for another as the main justification (18 per cent). The next two most common explanations, each given by 11% of smokers, were a lack of knowledge and safety worries.

According to Dockrell, some academic studies on "passive vaping" were reported in a misleading manner, and the concentrations of potentially dangerous chemicals in e-cigarette vapour were too low to have any effect comparable to that of tar and carbon monoxide, the most dangerous components of tobacco smoke. Despite being extremely addictive, nicotine itself is not considered to be carcinogenic (see What do we truly know about vaping?). It has even been compared to coffee in terms of danger, according to Peter Hajek and others.

Hajek criticizes the US attitude to e-cigarettes. According to him, studies that look at vaping over the previous 30 days run the danger of classifying kids' casual experimentation as longer-term usage. He challenges the notion that young vapers eventually switch to smoking. If anything, he argues, "it's the reverse." The introduction of substitute goods has expedited the drop in youth smoking. In Norway, young people seldom ever smoke. In Britain, 1.7% of those between the ages of 11 and 18 reported vaping weekly in 2016. Only 0.2% of those in the same age range who had never smoked reported vaping on a weekly basis. It is difficult to predict how many longer-term vapers—of any age—who have never smoked would have switched to smoking.

Twenty years after Dickinson had assisted in the development of NiQuitin, Ian Blandamer was so moved by his own decision to switch to vaping that, in January of last year, the two co-opened a vape shop in south London. Blandamer resents how tightening regulations on vaping make him feel like his former smoking self and is perplexed by the negative reaction to the e-cigarette.

Snus is no longer just a Scandinavian anomaly. In the US, where Swedish Match, the largest snus maker in Sweden and Norway, competes against the US Smokeless Tobacco Company (USSTC), a division of Altria, the parent company of Philip Morris USA, its usage has also gradually increased (and Marlboro). To produce Skoal Bandits, one of its products, USSTC constructed a snus facility in Scotland in the beginning of the 1980s. But safety worries suddenly surfaced 30 years prior to the vaping panic. In a 1985 article, The Mirror referred to the tobacco pouches as "cancer treats."

Snus was outlawed in 1990 by Kenneth Clarke, who was the UK's health secretary at the time (and later served as BAT's deputy chairman and director). In 1992, the EU adopted a similar policy before approving Sweden's exemption. The safety of snus and its possible attraction to non-smokers continue to be hotly contested issues in Norway. The local administration introduced basic snus packaging last year. Swedish snus cans sold in the US come with warning warnings stating that the substance "can cause oral cancer" and that it "is not a safe replacement to cigarettes." Although a review of research published in the Lancet did detect an increased risk of pancreatic and oesophageal cancers, the data actually indicates little to no rise in oral cancers among snus users in Europe.

Swedish Match disputes research that connect snus to cancer and claims that such warnings are unnecessary. Karl Lund is one of several independent snus as a quitting aid proponents who emphasizes how much less dangerous snus is than cigarettes. However, there are huge differences in how nicotine substitutes are regulated and perceived among nations. Australia and Canada are also rigorous with e-cigarettes, which are either prohibited or subject to restrictions in certain nations that produce tobacco. The government of Australia claims that the WHO's 2016 study warrants a cautious approach because e-cigarettes containing nicotine are prohibited there (cigarettes containing nicotine are not, but are taxed more than in any other country).

The tobacco industry, Lund's "good adversary," is particularly mentioned in Australia's strategy as needing to be protected against its interests. A tobacco corporation acquired the American blu eCigs brand in 2012, and it is now a part of Imperial Brands, which distributes e-cigarettes through its Fontem Ventures business. Vype electronic cigarettes were introduced by British American Tobacco in 2013, while Altria purchased a 35% share in Juul the previous year. Hon Lik, a Chinese pharmacist who is credited with creating the contemporary device, created the e-cigarette brand in 2013, which Imperial later bought. The lobbying against Australia's vaping laws that is most vocal and well-funded comes from Big Tobacco, not public health advocates.

Is it ultimately riskier for governments to regulate or even ban snus or vaping - for this or for safety concerns - even if doing so would be equivalent to smoking with the devil? Such restrictions, according to Hajek, "obviously protect the tobacco trade and hurt smokers." According to Robert West, nations with stricter vaping regulations frequently lag behind in tobacco control. "But if their regulation was similar to that in the UK I would predict that they would see smoking prevalence going down a little faster," he continues, citing Australia as the exception.

The same justification is used in Britain to call for easier access to e-cigarettes. After decades of legislation, advancement, and discussion, the percentage of adults who smoke, or 7.4 million people, fell to 15% in 2017. This decreased from 20% five years earlier. However, smoking still claims close to 100,000 lives in the UK each year. In a report released last year, the House of Commons Science and Technology Committee suggested that general practitioners (GPs) should have the authority to prescribe both e-cigarettes and nicotine replacement therapies. Harm reduction proponents, like ASH, contend that this would especially help lower-income communities, where smoking rates are still higher.

The fight against Big Tobacco has been hampered by vaping, which has also thwarted efforts to wean the globe off of nicotine. According to West, nicotine was remained "demonized" even when pharmaceutical medications were the preferred choice for smokers who wished to stop. "It was horrifying to think that you would give it to individuals to help them quit smoking. People were slow to accept the possibility that it may be helpful, and even then, they only used it briefly as a sort of stopgap measure between smoking and quitting for good.

Then came e-cigarettes, which individuals seemed to use for longer lengths of time, both when they were quitting smoking and for months or even years thereafter. 52 percent of the 3.2 million vapers in Britain last year were former smokers, while 44 percent continued to smoke in some capacity. These dual users represent a brand-new area of study. While switching is the aim, and the fraction of dual users among vapers is steadily declining, Hajek contends that any decrease in smoking is beneficial. Dual use has been shown to result in decreased toxin intake, he claims. Additionally, dual users are more likely to experiment with new gadgets when they become available, increasing the likelihood that they will completely give up smoking.

According to Hajek, critics seized on the study's 80% retention rate for vaping after a year as their main point of attack (with or without nicotine). In spite of the fact that they aren't now dying from lung disease, they claimed that this demonstrated that e-cigarettes don't assist individuals overcome nicotine addiction. The "moralistic" approach to nicotine annoys Hajek. "Somehow, it got into this 'war on drugs' mindset, where you have to get rid of it and if people are dying from it, that's a warning to others," he claims. "It's better to keep smokers smoking and risking death than to let them enjoy themselves risk-free."

Because of his position on snus, Karl Lund has been accused of abandoning his peers and working for Big Tobacco. Swedish Match has fought against limitations and prohibitions in court. It challenged the EU prohibition in front of the European Court of Justice last year, but it lost. The business, which gave up selling cigarettes in 1999 to concentrate on snus, sued the Norwegian government in 2017 over the country's new plain packaging regulations. Lund was brought in as an expert witness by the corporation, where he was pitted against some of his own coworkers who were testifying in favor of the government.

Lund claims that this "really caused problems in my department." But in Norway, you must appear in court if called. I then considered what to say. Lund acknowledged concerns that young people might be drawn to appealing packaging and branding, but predicted the overall effect of the plain packaging law would be to discourage people from switching from cigarettes to snus while adding to the perception that all nicotine products are roughly equally dangerous. (The public in Norway believes snus to be almost 80% as harmful as cigarettes, according to his research.) As he had anticipated, the court appearance brought on a fresh round of criticism. According to Lund, "The Ministry of Health didn't like this logic at all." "So once more, they believed I was betraying the policy. It was a terribly difficult time.

But Lund continues to believe that snus and electronic cigarettes may help end smoking once and for all. The old strategies for quitting smoking will only have minor success now, according to the hardening hypothesis, because the smokers who would benefit from them the most have already stopped. Lund advises "facilitating" the use of snus or e-cigarettes for individuals who cannot or won't use them. According to his study, snus appeals to both smokers who don't want to use patches and those who had never thought about quitting. He claims, "I honestly don't see a future for combustible cigarettes." If we keep enacting the measures we know work, West estimates that smoking rates in Britain might fall to as low as 5%.

Lund already anticipates the end of the smoking pandemic in high-income nations, which he terms the "ultimate stage" and predicts will also be accelerated by generational changes. In Norway, just 1% of women and 5% of males between the ages of 16 and 24 start smoking. He does not, however, foresee the end of nicotine itself. The more intriguing question, in his opinion, is whether society will permit snus and e-cigarettes in the event that these products eventually render smoking obsolete. Alternatives will no longer be useful when there is no smoking to control. Accordingly, "I believe that an even more passionate argument over the recreational use of nicotine will eventually replace the current hot debate on cigarette harm reduction."