In recent years, several governments have commissioned reports on the health effects of vaping. In addition to the 2018 report of the National Academies of Science and Medicine, reviews have been commissioned in the European Union, Australia, Spain and others.
Added to this list this week is a report from Sweden's Folkhalsomyngidheten, the Swedish Public Health Agency. The report was commissioned by the Swedish government in April 2022.
The results of this commissioned review were published in two parts: A plain-language summary of their findings and a description of the methods for the scientific review on which the conclusions were based. The release of the document was accompanied by a press release, in which the agency called for "expanded regulation", and the adoption of regulations "that is more similar to the protective legislation that exists for tobacco smoking, including bans on flavourings, regulation of nicotine content and marketing bans.
Sweden has unique circumstances with respect to tobacco. It is the only EU nation that is not required to ban the sale of oral tobacco, and Sweden has a long tradition of using snus and a lesser tradition of cigarette smoking than in most other European countries.
The preference for snus as a source of tobacco is not the only reason why cigarette smoking rates were lower in Sweden than elsewhere. Sweden maintained a government monopoly on tobacco until the early 1990s, which made it easier for the country to be one of the first to adopt comprehensive tobacco control measures - including powerful rotating health warning messages as early as the 1980s. Sweden's neutrality in the world wars also contributed, as it avoided the impact of soldiers returning from war addicted to smoking. The presence of a public broadcasting system which did not allow television advertising reduced the impact of tobacco marketing.
Prevalence of tobacco and nicotine use in Sweden
In this report, the Swedish Public Health Agency focused on the growing use of nicotine products by young people -- including traditional snus, nicotine pouches and e-cigarettes.
It found that snus use among girls in year 2 (grade 11) had tripled in five years - from 6% in 2018 to to 22% in 2022, shown below. At the same time, nicotine pouches and e-cigarettes had also become more popular with students. In the same grade, each of these products had been used by one in five students in the past month.
All told, almost one-fifth of women (19%) and one-third of Swedish men (31%) use some type of tobacco or nicotine product, either daily or occasionally, with many sourcing nicotine from more than one product type.
The health agency concluded different levels of relationships between smoking, snusing and vaping, finding a "likely" relationship between using e-cigarettes and subsequently smoking and "possible" relationship with snus. There were too few studies on nicotine pouches for them to make a finding.
"Among people who use e-cigarettes, there are more people who start smoking over time compared to people who do not use e-cigarettes. The result has moderate reliability, which means that it is likely that there is a relationship. The association is more reliable for people under 18, but it is possible that it also exists among adults. It is also likely that for people who use e-cigarettes, there are more who develop an ongoing use of smoking tobacco over time."
"Among people who snuff, there are more people who start smoking over time compared to people who don't snuff. The results have low reliability, which means that it is possible that there is a relationship. There are too few studies to draw conclusions about whether or not there is a connection between snuff and an ongoing use of smoking tobacco."
They did not conclude that using snus or e-cigarettes was associated with smoking cessation:
"Among people who smoke tobacco and who have also started using snus or e-cigarettes, it is not possible to draw any conclusions as to whether there is any connection with changed smoking habits or not. This applies to all kinds of changes, both smoking cessation and increased or decreased use of smoking tobacco. For e-cigarettes, this is because the studies that exist are not consistent. In the case of snus, there are too few studies to determine whether or not there is a connection."
Conclusions on health effects.
This report provides a plain-language summary of many health effects of tobacco and nicotine. A machine translation of the report's findings are printed below.
Health risks with the use of tobacco and nicotine products
In this chapter, we summarize the health risks associated with the use of tobacco and nicotine products. We begin by describing the health risks of each product. Next, we describe poisonings with tobacco and nicotine products.
Health risks with nicotine: Common to all tobacco and nicotine products is that they contain nicotine, which is acutely toxic and highly addictive. Nicotine addiction is characterized by withdrawal symptoms when you stop and by continuing to use products containing nicotine. The risk of nicotine addiction is affected by, among other things, the nicotine content and how the nicotine is administered.
Research into the effects of nicotine examines, among other things, how nicotine affects underlying mechanisms in the body that can increase the risk of developing diseases. Nicotine stimulates receptors found in many of the body's organs and tissues, and can affect, for example, regulation of the nervous system and the cardiovascular system. This research is largely based on cell and animal studies.
People who are exposed to nicotine can be affected in the short term through a deterioration in the functions of the blood vessels as well as increased heart rate and blood pressure. These effects on the heart and blood vessels can in the long run contribute to an increased risk of heart and blood vessel diseases.
Nicotine during pregnancy can pose risks for the woman, the fetus and the newborn child.
There is limited knowledge of nicotine's long-term health risks from human studies, among other things due to methodological limitations in isolating the effects of nicotine in tobacco and nicotine products. For more information on long-term health risks, we therefore refer to the sections on health risks with each individual product.
Health risks with smoking tobacco
There are various types of tobacco products for smoking, such as cigarettes, cigarillos, rolling tobacco, cigars, pipe tobacco, heated tobacco products and hookah tobacco. The smoke is harmful to health and may contain metals such as cadmium, lead and mercury but also many other harmful particles, substances and chemicals such as cyanide, arsenic, aldehydes, polycyclic aromatic hydrocarbons and nitrosamines.
Diseases of the respiratory system: Tobacco smoking damages tissue and cells in the airways and lungs and increases the risk of both acute respiratory problems and long-term problems such as cough, mucus formation and shortness of breath. Tobacco smoking is one of the main causes of COPD. People who have asthma and smoke risk worsening their asthma.
Cardiovascular diseases and type 2 diabetes: Tobacco smoking affects the heart and blood vessels negatively and increases the risk of developing high blood pressure, heart attack and stroke. Tobacco smoking also accelerates the development of atherosclerosis (arteriosclerosis), which in turn increases the risk of suffering from cardiovascular diseases. In addition, the risk of type 2 diabetes, which is a known risk factor for cardiovascular disease, increases.
Cancer: Tobacco smoking is the main cause of lung cancer, and also increases the risk of many other forms of cancer such as cancer of the esophagus, stomach, colon and rectum, bladder, kidneys and pancreas. People who continue to smoke after a cancer diagnosis have an increased risk of dying earlier from their cancer but also from other causes, compared to people who do not smoke. Quitting smoking improves the prognosis of people who have cancer.
Mortality: Tobacco smoking gives an increased risk of dying prematurely, regardless of cause, compared to people who do not smoke.
Risks during pregnancy and for the newborn baby: Tobacco smoking during pregnancy increases the risk of miscarriage, ectopic pregnancy and stillbirth. Furthermore, the risk of complications for the newborn child increases, such as certain congenital malformations (including cleft palate), reduced lung function and low birth weight. There is also an increased risk of sudden infant death syndrome during the first year of life.
Passive smoking indoors: People who do not smoke but are exposed to indoor tobacco smoke have an increased risk of coronary heart disease (for example heart attack) and lung cancer compared to people who are not exposed to such passive smoking. Children are particularly sensitive, and research shows, among other things, an increased risk of respiratory problems and impaired lung function and asthma in children who are exposed to tobacco smoke in their surroundings during their growing up years.
Health risks with snus
There are different types of snus with differences in content. In addition to nicotine, tobacco snuff can contain metals and other health-damaging substances and chemicals such as volatile organic compounds, polycyclic aromatic hydrocarbons and nitrosamines. Nicotine snus often contains plant fibers to which nicotine and various flavors have been added (28). The nicotine content of both tobacco snuff and nicotine snuff can differ between products.
Since the snus content varies between different countries, we focus on health risks with snus used in Sweden. The knowledge is based on what we know about tobacco snuff, because there is a lack of knowledge about the health risks of nicotine snuff.
Heart disease: Snuff can affect the heart and blood vessels by reducing the vessels' ability to dilate and raising blood pressure. However, it is not clear whether there is any connection between snuff and developing a heart attack or stroke. However, people who snuff seem to have an increased risk of dying within the first day after a heart attack compared to those who don't snuff. They also seem to have an increased risk of dying after a stroke at a follow-up time of an average of 17 years.
Type 2 diabetes: Type 2 diabetes is a known risk factor for cardiovascular disease, and people who snuff may have an increased risk of developing type 2 diabetes compared to those who do not snuff. The increased risk is mainly seen when consuming more than four doses a week.
Cancer: The connection between snuff and cancer is not entirely clear. Some studies indicate an increased risk for individual cancers, such as rectal cancer. For other forms of cancer, no increase in risk is seen or the basis is more uncertain to determine whether there is a connection or not. However, people who snuff seem to have an increased risk of dying after a cancer diagnosis compared to people who don't snuff. It concerns both cancer-specific mortality and mortality due to other causes.
Risks during pregnancy and for the newborn baby: Snuff use during pregnancy can increase the risk of complications such as premature birth or the fetus dying in the womb. Snuffing during pregnancy can also lead to disturbances in the breathing regulation of the newborn child.
Non-malignant changes in the oral cavity: Snuff can increase the risk of changes in the mucous membranes of the tongue and damage to the gums in the places where the snuff is placed
Health risks with e-cigarettes
The content of e-cigarette liquids can vary, but in addition to nicotine in different concentrations, the liquid can contain solvents, preservatives and various flavorings. In the liquids and in the steam, several harmful substances have been found, for example aluminum, lead and other metals, but also harmful particles, substances and chemicals such as aldehydes, polycyclic aromatic hydrocarbons and nitrosamines.
Effects in the short term: Most studies published to date on the health risks of e-cigarettes examine short-term effects. The research focuses, among other things, on the toxicity of e-cigarettes and the impact on underlying mechanisms in the body that can increase the risk of disease. Studies show, for example, that the use of e-cigarettes can disturb the heart rhythm, impair the functions of blood vessels and temporarily raise blood pressure and pulse. In the long run, this can contribute to an increased risk of heart and vascular diseases. Studies also suggest that its use can irritate the airways and worsen asthma symptoms.
Long-term health risks: Research on how e-cigarettes affect health in the long term is still very limited. This is because the products have not been used for so long and several years of research are required to investigate long-term effects. Therefore, we do not yet know whether e-cigarettes can increase the risk of cancer, cardiovascular disease and lung disease. There is also a lack of knowledge about the connection between e-cigarette use during pregnancy and possible complications for the woman, the fetus and the newborn child. It is also not known how the health of people exposed to the vapor from e-cigarettes is affected.
Poisoning with tobacco and nicotine products
Tobacco and nicotine products can cause poisoning. Assessment of the risks of poisoning by ingestion and exposure to tobacco and nicotine products depends, among other things, on the type of product, the route of administration and the nicotine content.
Poisoning offer: In 2021, 1,480 inquiries about tobacco and nicotine products were received by the Poisons Information Centre. The majority of conversations concerned snuff. Calls about poisoning incidents linked to snus ingestion have increased over the past ten years, and snus ingestion is one of the most common reasons for calls involving children (30).
Risks of acute poisoning: The nicotine in snus is absorbed from the oral mucosa and stomach. Ingesting snus can cause symptoms such as vomiting, cold sweats, lethargy and palpitations (30).
The nicotine in e-cigarette liquid is absorbed through the oral mucosa and stomach. Ingestion of e-cigarette liquid with nicotine can quickly cause symptoms in the form of vomiting, cold sweats, lethargy and palpitations. In severe cases, convulsions and effects on pulse, blood pressure and breathing can occur. Deaths have also occurred. At contact, the e-cigarette liquid can cause damage to the eyes and skin. Nicotine can also be absorbed through the skin (30).
Smoking tobacco, for example cigarettes, does not lead to poisoning when ingested as a rule because the nicotine is then not absorbed to such a large extent. The most common symptoms in children are nausea and vomiting (30).
Hookah use risks leading to carbon monoxide poisoning. The symptoms are, for example, nausea, headache, vomiting and, in severe cases, unconsciousness. In addition to the acute risks of carbon monoxide inhalation, there is a risk of neurological damage (30).
