Sesh+: Another nicotine product hits convenience store shelves

Almost a generation of Canadian children have grown up without ever seeing a display of cigarettes in corner stores. Almost three years have passed since corner stores across Canada were required to take down promotional displays of electronic nicotine products. 

And yet self-service displays of nicotine products are once again beside the cash registers across Canada. Since January, Circle K, Shell and other retailers have supported the national launch of a modernized nicotine gum sold under the brand Sesh+.

Sesh+ display at Shell
Station

The federal law which governs these products does not include restrictions on paid promotional displays.  

Sesh+: not your father's NRT

Sesh+ distinguishes itself from the more staid NRT manufactured by established consumer pharmaceutical companies. 

• it is sold in convenience stores, not pharmacies
• it is packaged to resemble ordinary chewing gum
• the outer-labelling does not indicate that it is intended for therapeutic use
• it is sold in more exotic flavours (i.e. pomegranate)
• it is sold in smaller packages with a lower price (SRP $8.99)

Sesh+: A Canadian start-up with an American footprint. 

Sesh products is owned and operated out of Vancouver, B.C. It was incorporated in Canada in November 2020 and a year later in the United States. In September 2021, the company applied to trademark its brand for both nicotine gum and pouches. 

Sesh+ nicotine gum are reported to have first appeared in stores in April 2022. Sesh+ nicotine pouches are sold on-line to Canada from the United States, but are not legal for sale in stores. Sesh Products does not manufacture either Sesh+ gum or pouches, but sells gum made in the United States and pouches made in Sweden.

From the registration on Health Canada's Licensed Natural Health Products Database, it is evident that Sesh+ gum is the same as the nicotine gum sold in the United States under the Lucy brand name. They share the same Natural Product Number (NPN 80108821). The same NPN number is used on Luy Brand Spearmint, Citrus Berry and Red Mango (available online only), and on Sesh+ branded flavours  cinnamon, wintergreen and pomegranate.

Sesh+ and Lucy are the same product sold in Canada different flavours
under different names. They share a Natural Products number. 

Sesh+:  Marketing hype or new nicotine formulations?

The Sesh+/Lucy nicotine gum is promoted as being different (and better) than Nicorette and other established brands. These marketing claims are considerably more subtle in Canada than in the U.S. 

In Canada, the product is promoted by Mr. Cunningham as a product which overcomes the "negative stigma around trying to overcome addiction, the toll on mental health, and asking for support ... Sesh+ was my way of providing people with something that I knew worked, was accessible, delicious, and not something you needed to hide.”

The Canadian web-site for the product says little about the ingredients. (The Health Canada registration identifies 23 non-medicinal ingredients, which are collectively described here as "food-grade ingredients").  The formulation of the nicotine in Seth+ that is reported to Health Canada is 2-Propenoic acid, 2-methyl-, polymer with diethenylbenzene, compd. with 3-((2S)-1-methyl-2-pyrrolinidinyl)pyridine. 

By contrast, American consumers are given more information on the product by the distributors of Lucy. The website for Lucy claims that the gum differs from others in part because the nicotine has been altered to provide a quicker nicotine hit.

 

pH Adjusters. We use a customized buffering system which interacts with the nicotine as it is released from the resinate and gum matrix in order to maximize buccal absorption. Absorption of nicotine across the buccal membrane depends on the amount of nicotine present in the unionized “free base” form. In an acidic (low) pH, nicotine is ionized and does not cross biological membranes, whereas in an alkaline (high) pH environment, nicotine is un-ionized and readily absorbed. We invested a lot of effort into ensuring that our buffering system maximizes the amount of free base nicotine while avoiding the acrid taste of standard buffer systems.

Sesh+: an offshoot from the tobacco industry 

The founder and owner, Max Cunningham, is not new to the nicotine market, having once worked to promote products for Imperial Tobacco. He identifies on his LinkedIn profile that prior to working full time on Sesh+ in September 2021 he worked for Market Recon where he "created and executed marketing and sales strategies on behalf of one of the world's largest tobacco company's for their next generation product category."  (Market Recon supplies retail promotions and brand activation for Imperial Tobacco).

Mr. Cunningham says his motivation for entering the business was his own addiction to vaping. “Like many young adults around the world, when vaping first hit the market, I thought it caused no real harm to my health. But shortly after I started, I felt my physical health decline specifically in my lungs and shortness of breath. Once I noticed the negative effects on my body I knew I had to quit, but after a couple of failed tries I realized it wasn’t that simple.”  

Sesh+ gum: Good or bad for public Health?

Some may see the sale of Sesh+ in corner stores as a health benefit, in the expectation that selling smoking cessation medications in the same locations as tobacco products can make it easier for smokers to make a quit attempt. They may also consider attractive flavourings and accelerated nicotine delivery as helpful to sustaining quit attempts. From this perspective, the appearance of Sesh+ on convenience store counters could benefit public health.

On the other hand, there are reasons to be concerned that the way this product is marketed could produce harms that exceed any benefits. These include the likelihood that the benefits will be small, as the evidence to date suggests that nicotine gum when sold over the counter does not increase quitting rates.(1) Because most of the customers in corner stores are not smokers or vapers, the risk that impulse tries will be by non-smokers and the product may recruit non-smokers to nicotine use cannot be discounted. Contributing to this risk is the generally appealing design of the packaging, the noticeability of the counter-top promotions, the attractive product flavourings and the affordability of a trial pack. Although the package carries a caution that the product should not be used by anyone but daily smokers, it is in very very small print and is unlikely to be seen until after purchase.

In article published last year, U.S. researchers raised concerns about the public health risks presented by Lucy (Seth+) gum (2), "We believe that Lucy’s packaging similarities to chewing gum, lack of warning information, and noted dissimilarities to other smokeless tobacco products may attract youth and non-nicotine-users to initiate nicotine use."

Sesh+:  Exposing the cracks in Canada's nicotine policy

The launch of this product is a stark reminder that the era of "good/therapeutic nicotine" (produced by big pharmaceutical companies and sold mostly in pharmacies) and "bad/harmful nicotine" (produced by big tobacco companies and sold mostly in convenience stores) is over. Manufacturers and governments have deliberately blurred this line. 

Tobacco companies have blurred the line by presenting vaping products, heated tobacco and modern oral nicotine as though they have health benefits, although the products have not been authorized for sale as pharmaceutical, natural health products or medical devices. The major companies are also expanding into the area of authorized medications. Eighteen months ago, for example,  Philip Morris International purchased Fertin Pharma, which specialized in gum-and other oral delivery systems for drugs and which has research and manufacturing facilities in Canada.

Canada's federal government has blurred the line through its heterogenous nicotine policies. The right hand of Health Canada's Health Products and Food branch regulates nicotine gum and pouches as natural health products (and requires market authorization before sales are legal). Nicotine gum or pouches are legal for sale without prescription in Canada provided  that they contain less than 4 mg of nicotine, and also that they are registered with Health Canada as a Natural Health Product. To date, market authorization has not been granted to any nicotine pouch applications. The department has already forced recall of nicotine pouches after attempts to sell them in Canada (including Seth).  Meanwhile, the left hand of the Controlled Substances and Cannabis Branch permits any vaping or tobacco product to be offered for sale without pre-approval. 

Although the law forbids promotional claims that vaping products are safer than cigarettes, the companies have been permitted to promote their products as being reduced risk.

An integrated nicotine policy is not yet in place

Health Canada has not yet established an integrated nicotine regulatory framework to address the expanding range of nicotine formulations which are neither short-term medications nor combustible tobacco. In the absence of such a framework, we can expect to see more innovations like Sesh+ exploit the in-between market for nicotine. 

In the meantime, provincial governments can help by banning self-serve displays of nicotine products sold outside of pharmacies and by reviewing the appropriateness of addictive products like nicotine being sold in convenience stores. The Netherlands provides an example of how this can be approached: it has adopted a staged approach that has already reduced the outlets that can sell tobacco and which will place them in adult-only specialty shops in 2032. (3)

References

(1) Walsh RA. Over-the-counter nicotine replacement therapy: a methodological review of the evidence supporting its effectiveness. Drug Alcohol Rev. 2008 Sep;27(5):529-47. doi: 10.1080/09595230802245527. PMID: 18696300.

(2) Unger JB, Barker J, Cruz TB, Leventhal AM, Pentz MA. Lucy-Novel Flavored Nicotine Gum, Lozenges, and Pouches: Are They Misleading Consumers? Subst Use Misuse. 2022;57(8):1328-1331. doi: 10.1080/10826084.2022.2076881. Epub 2022 May 19. PMID: 35586938; PMCID: PMC9451008.

(3) Nagelhout GE, Poole NL, Metze M, Willemsen MC, Vermeulen W, van den Brand FA. Reducing the number and types of tobacco retail outlets in the Netherlands: Study protocol for a comprehensive mixedmethods policy evaluation. Tobacco Prevention & Cessation. 2023;9(March):8. doi:10.18332/tpc/161825.

 Thank you to a colleague who drew our attention to this product.

Growing support in Europe for banning cigarette filters

This month the neighbouring European countries of Belgium and the Netherlands took important steps towards banning cigarette filters. 

The Netherlands Environment Minister advocates a ban on filter

Last week Vivianne Heijnen, the Netherlands Minister of Environment, informed her colleagues at the House of Representatives that after reviewing the alternatives, she considered that a ban on cigarette filters was necessary to achieve that country's environmental objectives. (A machine translation of her letter is pasted below).

This opinion was informed by a report she commissioned from the consultancy DE Delft, which had been provided to the legislature in February.  This study had included a forecast of the impact of expected reductions in tobacco use, and whether 5 suggested approaches would be effective. Public opinion and legal considerations were also taken into account.

The report and the Minister's opinion both conclude that the EU context complicates the ability of the Netherlands to impose a unilateral ban, but that the drafting of a new EU Directive is an opportunity to establish national authority for the measure. The Minister stated her intention work with EU colleagues to this effect. 

The Belgian High Council on Health recommends a ban on filters

The Belgian government established integrated department responsible for public health, food safety and the environment. ( FPS Public Health, Food Chain Safety and Environment).

This week the department released the results of a review it conducted at the request of the Belgian Minister of the Environment. 

The 49 page report "The Impact of Cigarette Filters on Public Health and the Belgian Environment" is available in English, and the conclusion is summarized in the Council's press release.

The analysis shows that filters in cigarettes do not in fact reduce the harmful health consequences of smoking. From a public health perspective, they do not offer any benefit, while they pollute the environment. The Superior Health Council therefore recommends introducing a general ban on cigarette filters, both at national level and at international, and therefore European, level.

In the report, the Council rejected the concept of filter alternatives: "The Superior Health Council sees no solution in advocating "green" biodegradable filters. Given that there are no significant health benefits for smokers, people might even be more prone to throw away cigarette filters in the environment because of the misleading "green" image."

The continuing divide on E-cigarettes for smoking cessation: Part 1 - research findings

One of the few agreements about e-cigarettes is that there is still no consensus about the role they play in helping smokers quit.

This post reports on the conflicting (and missing) evidence on the effects of using e-cigarettes for smoking cessation. A subsequent post will look at the conflicting (and missing) approaches to promoting e-cigarettes for quitting that have been recently adopted by health authorities.
More evidence that reviewers disagree

At the beginning of this month, yet another review of evidence on e-cigarettes as cessation devices was published. This umbrella review of the health outcomes of e-cigarettes [1] was conducted by a team headed by Dr. Banks, and is the a journal version of a study commissioned by the Australian government. [2]

• there was limited evidence that using freebase nicotine e-cigarettes with clinical support was more effective than NRT or nothing, 
• there was insufficient evidence that freebase nicotine e-cigarettes were effective when used outside a clinical context.
• there was no evidence on the impact of nicotine salt products (found in capsule and disposable cigarettes) for cessation.
• there was insufficient evidence that free-base  nicotine e-cigarettes were more effective than those with no nicotine.

Banks et al conclusions on e-cigarettes for cessation

There are now more than a dozen systematic reviews and meta-analyses looking at a smaller number of randomized control trials comparing e-cigarettes with NRT or no intervention to help smokers quit. (A list of these reviews can be downloaded here.) In this case, the hierarchy of evidence looks more like a cube than a pyramid!

Generally these reviews concur that e-cigarettes in clinical settings (often with counselling or other support) have performed as well or better than NRT. They often disagree about how strong this evidence is, or its generalizability to real-world circumstances, or the usefulness of these experiments for clinicians, policy-makers or and smokers.

Among these, the greatest enthusiasm is expressed by the Cochrane Tobacco Addiction Group.[3] Where the Australians and others have concluded there is "limited evidence" that e-cigarettes outperform NRT, the Cochrane group finds "high certainty evidence". (Our report on their review can be found here).

In addition to the Banks' team review, the three other reviews published over the last year were much more cautious. A French research team noted that "there have only been few studies carried out, which does not allow for an affirmation and recommendation of practice." [4] A Chinese research team characterized the evidence on the effectiveness of e-cigarettes as "low certainty." [5]

Press material released with Cochrane Report 
November 2022

Explaining the difference

How can similarly-trained researchers consider the same body of evidence and produce such different conclusions? Factors that may play a role are the independence of the reviewers, their choice of studies to include and exclude, the role of the tobacco industry, the preferences of publishers, and geography.

Independence from primary studies

Dr. Banks' team explained its concerns with the Cochrane analysis: "We rated it less independent than other reviews because four of its authors were also investigators in the included trials ... The review inclusion criteria were broader than ours, including self‐reported cessation outcomes and trials not published as peer‐reviewed articles, and the authors generally rated risk of bias in individual trials lower than we did."

This polite wording points to concerns others have raised about the personal connection of the Cochrane reviewers to the original studies and also their inclusion of a study conducted by tobacco companies.

The Cochrane group selected only five studies for its meta-analysis, three of which they had conducted themselves and one of which was paid for by an e-cigarette manufacturer. Shown below is a table taken from the pay-walled full version of the Cochrane report which has been annotated to identify those studies which were authored by Cochrane reviewers and those which were industry funded.

Independence from tobacco industry

More than one-third of the results of the Cochrane meta-analysis are derived from two arms of a study conducted by the U.K.-based Centre for Substance Use Research (CSUR). This firm is funded by tobacco and nicotine companies. A core part of its business is supporting applications to the FDA related to market authorization for e-cigarettes.

The study in question has not yet been published in any journal. Its results are available only in the form of an abstract (PH 353) presented at the 2021 SRNT Conference.[6] The abstract acknowledges funding to the "E-cigarette/Alternative nicotine products Industry". The device tested in the trial (myBlu) is manufactured by Fontem, which is a division of the world's fourth largest tobacco company, UK-based Imperial Brands.

It seems probable that the study was conducted to support an application to the US FDA for permission to market myBlu. Shortly after the results were shared at the 2021 SRNT conference, the U.S. FDA issued a marketing denial order for myBlu. The letter sent by the FDA to Imperial Brands e-cigarette division (FONTEM) provides the reasons for denying the application, but does not identify any studies by name.

In addition to being industry-funded and unpublished, there is another red-flag attached to this study. CSUR failed to prospectively register its trial of myBlu. All those who conduct clinical trials are expected to register them in advance in order to reduce the likelihood that only positive results will be shared. The duty to register is no minor obligation - the World Health Organization describes it as a "scientific, ethical and moral responsibility". The Cochrane organization (which oversees the Cochrane Tobacco Addiction Group) also expects prospective registration of all trials.

Systemic influences on favourable results for e-cigarettes

Mexican researchers recently reviewed almost 700 articles on electronic cigarettes, assessing the relationship between reported conflicts of interest and the research conclusions of each paper. Their results were published last summer in the Journal of the Pan American Health Organization. [7]. This paper did not consider results of unpublished research like the CSUR study included in the Cochrane review.

This study found that articles in which any conflict of interest was reported were almost 5 times more likely to find a positive result for vaping (OR 4.7; 95% CI 2.89-7.65). Papers that were funded by tobacco companies were 30 times more likely to have positive results (OR 29.95; 95% CI 9.84 - 90.98).

They also found other patterns related to geography and editorial selection: papers published in England had more than twice the rate of positive results as those published elsewhere. These results are shown in the table below.

Factors associated with a positive result
of vaping studies, Vidana-Perez et al, 2022

And what about the unpublished results of other trials?

The number of RCT's comparing the use of e-cigarettes for quitting smoking published by 2021 hovers around a dozen (see, for example, the list collected by the Irish Research Board).[8] But there are a great number of unpublished trials registered - some of which are newly started, but many of which have been underway for several years. The absence of any reports on these trials raises concerns about publication bias.

These unpublished results include trials conducted by the tobacco-industry funded team in Italy. (NCT01979796, registered in 2013; NCT02124187, registered in 2014), as well as a study by Cochrane Tobacco Addiction Group member Peter Hajek (NCT01842828, registered in 2013). A Canadian trial of e-cigarettes for inner-city substance users was registered in 2017 and has also seemingly dropped from view (NCT03249428).

Other large trials in Europe have been completed or are close to completion, but the results are not yet shared. These include the Swiss ESTxENDS trial of 1,246 would-be quitters (NCT03603340), the French ECSMOKE trial of 650 comparison e-cigarettes with varenicline (NCT03630614) and a similar trial of 450 middle-aged heavy smokers in Finland (NCT03235505). A study comparing e-cigarettes and NRT with telephone quitline support among 926 Australians is expected to finish data collection this summer. (ACTRN12619001787178).

And there is more to come. Many new trials have recently been registered. Included in these is a study with 800 Canadian smokers which will compare e-cigarettes with varenicline (NCT05715164).

The results of these trials may contribute to a consensus among independent reviewers of the efficacy of e-cigarettes to help people quit in the short term. They are not designed to address questions about long-term impact.

Clinical trials, real-world experience, professional concerns of health practitioners

E-cigarettes are sold worldwide as consumer products, and nowhere yet are they authorized as medicines or therapeutic devices. The RCTs discussed above focus only using these products in structured clinical settings. Other approaches (longitudinal studies, cross sectional studies) are designed to assess real-world outcomes outside the clinical setting or in the natural history of nicotine use.

Many real-world studies have been conducted and a handful of systematic reviews of these studies have also been published. [9, 10, 11] These reviewers generally concur with the findings of Banks et al, discussed above, that there is insufficient evidence to conclude that e-cigarettes are effective in non-clinical circumstances. The results of cohort studies, shown below, is taken from a meta-analysis conducted by a Swedish research team.

Hedman et al. 
Electronic cigarette use and smoking cessation
 in cohort studies and randomized trials:
A systematic review and meta-analysis

Evidence based medicine relies on approved products

Using a system designed to assess therapeutic drugs to evaluate consumer product use creates additional complexities. In many countries, clinicians are bound by codes of practice which require them to recommend drugs whose safety and efficacy has been established by health authorities. This is not the case with e-cigarettes. (Australia's requirement for e-cigarette prescription is based on that country's special rules for "unapproved therapeutic goods").

In short - the evidence in support of clinical use of e-cigarettes is of limited value to clinicians who are professionally obligated to recommend medications that have been evaluated and authorized and for whom evidence for different formulations and dosages is expected .

This may contribute to the assessment by the leading health agencies that e-cigarettes should not be recommended as smoking cessation interventions. This is the advice of the World Health Organization, the U.S. Surgeon General, the U.S. National Institute on Drug Abuse, U.S. Centre for Disease Control and Prevention, Direccion General de Salud Publica (Spain), Haut Conseil de la Santé Publique (France), the Instituto Nacional de Salud Pública (Mexico) and many others. A list of statements by these and the organizations shown below can be downloaded here. This week another organization - the Academy of American Pediatrics- joined the list.

PSC Presentation on Evidence of e-cigarettes
for cessation, April 2023

Dutch health agency suggests ways to reduce the attractiveness and addictiveness of cigarettes (and e-cigarettes)

When the Framework Convention on Tobacco Control was finalized twenty years ago, it identified the need for product standards for tobacco, but kicked the setting of such standards down the road. "The Conference of the Parties, in consultation with competent international bodies, shall propose guidelines for testing and measuring the contents and emissions of tobacco products, and for the regulation of these contents and emissions."  (Article 9)

In the decades since then, experts have been tasked with providing guidance for tobacco regulation. This work resulted in the partial FCTC guidelines on articles 9 and 10 that were adopted in 2012 and updated in 2017, which provide general encouragement for governments to make tobacco products less attractive cigarettes and leave the issue of how to reduce their addictiveness for future consideration.  Another group convened by the World Health Organization - the WHO Study Group on Tobacco Product Regulation (TobReg) - meets periodically to consider and report on tobacco regulation. 

Translating recommendations from these bodies into domestic regulation to make cigarettes less addictive and less attractive into has proven challenging. Even Health Canada, which pioneered many tobacco product regulations - has hesitated to tinker with the basic design of cigarettes or e-cigarettes. New Zealand's Smoke Free Action Plan announced in December 2021 was the first to include the goal of "Making it easier to quit and harder to become addicted by only having low-level nicotine smoked tobacco products for sale and restricting product design features that increase their appeal and addictiveness."

More leadership was provided this week by the RIVM, the Netherlands' National Institute for Public Health and the Environment. Twin documents were released which explain in legislator-friendly language how governments can achieve these goals. The first provides "Options to make cigarettes less appealing and addictive". The second -  a "Recommended Dutch list of prohibited additives in tobacco products and e-cigarettes." - provides details on the chemicals that need to be banned to make this happen. An important conclusion of RIVM is that  salt nicotine should be banned in cigarettes and e-cigarettes. 

RIVM is a government agency owned by but working independently from the Ministry of Health. Its advice is intended to assist the Dutch government, but is useful too for those in other countries. The measures proposed by RIVM could be implemented in Canada by federal or provincial governments, as tobacco is an area of shared jurisdiction.

The Netherlands plan for a smoke-free generation by 2040

For the past few years, the Netherlands' approach to tobacco regulation has been guided by the National Prevention Agreement endorsed by the government and more than 70 civil society organizations. Among the goals of that plan is the achievement of a smoke-free generation by 2040 and ensuring "by that time no more children will be smoking and that no children will ever smoke again". 

This agreement has spurred the implementation of a number of measures already in place in Canada, including smoke-free spaces, retail display bans and plain packaging, and the development of the goal of restricting tobacco and e-cigarette sales to adult-only specialty shops. It was also the springboard for the Netherlands adopting other measures not yet in place in Canada - like restrictions on flavourings in vaping liquids. This week's guidance from RIVM encourages governments to add another policy lever by "imposing tighter restrictions on the appearance and composition of cigarettes ... to make them less appealing and addictive."

FIVE product regulations to reduce cigarette appeal

RIVM describes its 5 options as follows:

1) Ban the use of filter ventilation. This way, manufacturers can no longer give the impression that some types of cigarettes cause less harm. In addition, policymakers could consider banning filters entirely. This would also protect the environment. Filters are made from plastics that do not break down well. This means they stay in the environment as microplastics for many years.

2) Expand standard requirements for cigarettes appearance to make them even less appealing. For example, policymakers could obligate manufacturers to make cigarettes a darker colour or to print a health warning on cigarettes.

3) Lower the nicotine content of cigarettes to a very low level (0.4 instead of 16 milligrams per gram of tobacco). This will make them less addictive. Public communication is an important part of this. Consumers need to know that these cigarettes cause no less harm than cigarettes with a ‘regular’ level of nicotine. They are only less addictive.

4) Ban ingredients that make cigarettes more appealing to new smokers, such as sugars and flavourings. They also make it more difficult for current smokers to stop smoking. Ingredients that make it easier to inhale cigarette smoke are already banned for this reason. Policymakers should make clear which ingredients are banned and make sure that these ingredients are no longer added to cigarettes. They could do this by creating a list of ingredients for which the ban can be enforced.

5) If policymakers implement stricter requirements for cigarettes, smokers may start using other, less regulated products.  Policymakers can prevent this by making sure that these recommendations also apply to other tobacco products and related products.

Norway sets a new path for tobacco control

 
Last week the government of Norway published a new national health strategy. In its 146 pages, the strategy document covers a wide range of health issues with the overarching goal of reducing health inequalities. Included in this plan is an articulation of Norway's new approach to tobacco and vaping.  

Among the government's plans are:

• a new national smoking cessation program
• standardised packaging for e-cigarettes
• flavour restrictions on e-cigarettes
• banning on remote (e-sales) of tobacco and e-cigarettes
• restrictions on specialty shops in order to reduce their promotional impact.  
• tobacco free generation for those born after 2010 (including e-cigarettes and snus).
• banning on smoking in private buildings with children, in outdoor playgrounds, sports area and in other common areas.
• higher taxes on tobacco products etc, and stronger cooperation between the health and customs authorities to address illegal tobacco imports,
• expanded public campaigns to encourage quitting and to prevent starting.
• advance implementation of FCTC Article 5.3 with "legislative support, information measures and guidelines" for public employees. 
• expanded reporting requirements for tobacco companies and consideration for maximum limits for inhalants 
• requirement for tobacco companies to pay for the costs of clean-up of tobacco waste.
• address advertising for tobacco and e-cigarettes in social media. 
• requiring warnings on individual cigarettes

In developing this strategy, the Norwegian government has identified 6 main goals:

• Daily smoking and snus use will be below 5 per cent in all age and educational groups.
• Children born in 2010 and later will not use tobacco or related products
•  Everyone who wishes to quit should be offered free help to do so.
• Access to tobacco products etc. will be substantially reduced to protect children and young people.
• No one should be bothered by secondhand smoke.
• The tobacco industry should not be able to influence tobacco policy, in line with our international obligations.

The plan "Folkehelsemeldinga Nasjonal strategi for utjamning av sosiale helseforskjellar" can be downloaded here.

The Norwegian context

Norway, like Canada, is a rich country with a mixed economy and a well-developed health care system. The population, at 5.6 million, is about the same as that of British Columbia.  Norway, with its large market for snus products, has a long experience in "reduced harm" products.

Norway is not a member of the European Union, and has only recently agreed to align its policies with the EU Tobacco Directive. The transition is expected in 2023. E-cigarettes remain illegal in Norway, but will become legal when the transition to the EU directive is complete. Regulations are being prepared to support the transition.

Although Norway has roughly the same percentage of people who smoking cigarettes daily as in Canada (7% vs. 8.4%)  it has a much higher proportion who smoke on an occasional basis (8% vs. 3.4%). As a result, the overall rates of current smoking are higher in Norway (16%) than in Canada (11.8%). Twenty years ago, the difference was much greater.

Data from FHI and Statistics Canada (CCHS)

As in Canada, the percentage of young people who smoke tobacco has fallen dramatically, but in Norway this has been accompanied by an increase in snus use, whereas in Canada it is e-cigarette use that has grown.

In Norway, the proportion of people who snus daily is higher than those who smoke daily: 1 in 5 men (21%) and 1 in 10 women (9%). Snus use is highest in the  younger age groups. 

Among Norwegian men, snus use is highest
among young adults (16 to 24)

Over-all past-month e-cigarette use is higher in Canada (5%)  than in Norway (3%) - the illegal status of e-cigarettes in Norway will likely have contributed to this difference. Rates of e-cigarette use among young people in Norway remain low. 

Unlike Canada, Young people in Norway are only slightly
more likely to use e-cigarettes than older people.

Further information from the Norwegian public health institute (FHI) on historic smoking and snus use can be found here.