Toward a smoke-free Nigeria: Lessons from Sweden's success

Nigeria is one of the African countries with the highest burden of tobacco-related diseases and deaths. Unfortunately, the National Tobacco Control Act 2015 has been slow and inadequate in addressing the challenge. This apparent failure can be mitigated by awareness and acceptance of Tobacco Harm Reduction (THR) strategies. THR aims to reduce the risks associated with tobacco use by providing safer alternatives to combustible cigarettes. Its remarkably successful adoption in Sweden accounts for the country's lowest rates of smoking prevalence in Europe and the consequent lowest rates of lung cancer and cardiovascular diseases in the world. Much of this outstanding smoke-free success in Sweden is primarily due to the widespread use of snus; a smokeless tobacco product that delivers nicotine without combustion as well as adoption of other non-tobacco alternatives to smoking. A significant body of evidence shows that these options are safer than smoking, incentivizing millions of Swedes to switch from cigarettes to these options.

Nigeria inarguably needs to emulate Sweden to become smoke-free in the shortest possible time. In a 2021 study by Marco Castrodori of the Center for the Study of Economies in Africa (CSEA), Nigeria recorded 28,876 tobacco smoking-related deaths annually, imposing an economic burden of approximately N526.4 billion in treatment costs. A glimmer of hope, however, surfaces as recorded deaths have declined to 16,137 annually as of 2023. Again, a study on the Current Prevalence Pattern of Tobacco Smoking in Nigeria by Adeloye et al. (2019) published in the BMC Public Health journal reported similar declines in smoking rates, which fell from approximately 13 million smokers in 2012 to around 11 million in 2015. Similarly, in 2022, the Global State of Tobacco Harm Reduction report, further updated in October 2023, showed that between 2000 and 2023, Nigeria witnessed a commendable decline in smoking prevalence. The tobacco smoking prevalence dropped from 7.5% in 2000 to 6% in 2015, with an anticipated further decrease to 5% by 2025. While these numbers reflect progress, more strategic adoption of tobacco harm reduction techniques will accelerate these achievements.

The game-changing strategy of Sweden, which remarkably reduced its smoking rate from 15% in 2008 to 5.6% in 2023, is the guide that Nigeria requires to further accelerate the decline in smoking. They sit on two strategic planks: enforcing policies to reduce exposure to smoke and introducing Tobacco Harm Reduction (THR) reduced-risk products to replace combustible tobacco. Like most other countries, Sweden has implemented a comprehensive tobacco control strategy since 1994, including increasing cigarette taxes, smoke-free air policies, and strengthening health warnings. However, while Sweden's broad tobacco control measures are crucial, introducing Tobacco Harm Reduction (THR) reduced-risk products emerged as a game-changer. The expansive adoption of THR measures, alongside THR products relative to other countries, has contributed to the accelerated decline in smoking prevalence and its clear global leadership in smoke-free rankings.

THR products are alternatives to smoking, purposed to reduce the harm associated with conventional cigarettes. Examples include snus, heated tobacco, e-cigarettes and nicotine pouches, which are viable alternatives to combustible tobacco. Tobacco heating products [THPs] heat tobacco to generate an aerosol. Snus, a smokeless tobacco product in pouches, has shown tangible harm reduction benefits. E-cigarettes, producing vapour instead of smoke, have been endorsed as less harmful by the National Academies of Science, Engineering, and Medicine. Vapour products are gadgets that heat liquid compositions using batteries to create a vapour. Heated tobacco devices have demonstrated a decrease in cigarette sales, and nicotine pouches offer a smoke-free option. Modern oral products include tobacco-free nicotine pouches. Research has shown that alternative tobacco products, such as e-cigarettes, heated tobacco products, and oral nicotine products like snus and nicotine pouches, can serve as options for adult smokers who switch to these alternatives, thereby potentially reducing the harm associated with smoking. It is noteworthy that the tax rates for alternative tobacco products are often lower than those for combustible cigarettes, reflecting the lower risk associated with these products.

Maximum success in emulating Sweden's steps means that harm reduction should guide tobacco regulations in Africa, as it is a more practical and transformative approach than prohibition-based policies. The term "harm reduction" describes actions meant to lessen the harmful effects of health behaviours without necessarily eliminating problematic health behaviours, which is better than simply advocating for complete abstinence. Complete abstinence is often fraught with difficulties in maintaining and sustaining the practice on the part of the user. Nigeria should, therefore, adopt harm reduction approaches when regulating incalcitrant public health challenges for several reasons. First, harm reduction integrates public health initiatives driven by the community, such as risk reduction, health promotion, and prevention, to empower those who utilize tobacco and their families with the choice to live healthy and self-directed. Second, it is a practical and transformative strategy that addresses the adverse effects of health behaviours while acknowledging the complexity of human behaviour change. Third, it alleviates the strain on healthcare systems. By prioritizing and implementing tobacco harm reduction initiatives, Nigeria can save millions of lives, lessen the stress on healthcare systems, and work towards a healthier future for its people. Fourth, amplify the voice of harm reduction advocacy, urging the government to integrate harm reduction principles and practices when regulating public health challenges.

An analysis of Sweden's approach to smoke-free reveals a combination of sound THR policies and their robust implementation. First, Sweden created a foundation for collaboration among the government, health professionals, industry stakeholders, and consumers, aiming to minimize the consumption of combustible tobacco products and reduce exposure to tobacco smoke. The legal acceptance of these products and awareness campaigns targeting healthcare workers, smokers, and the general public played a significant role. Health workers actively recommended Harm Reduction Products as alternatives to combustible tobacco, creating a joint effort to combat smoking-related diseases.

The second was that they legalized 95% of the less harmful alternatives to combustible tobacco products and substantially reduced the attendant taxes on these alternative products based on the relative risk reduction of these products as compared with cigarettes. This approach provides legal options for smokers looking to quit, such as snus, heated tobacco, tobacco-free nicotine pouches, and e-cigarettes. Importantly, these alternatives were made readily available, with extensive advertising to raise awareness.

Lowering taxes on these alternative products made them more affordable than traditional cigarettes. Sweden's Finance Minister, Mikael Damberg, noted that products were taxed based on risk, with less harmful alternatives having lower taxes. As of January 1, 2023, the tax on tobacco-heated products and combustible cigarettes was 36%, while nicotine pouches had taxes as low as 8%. This affordability incentivized smokers to choose these alternatives without financial barriers. These non-combustible tobacco products, proven to be 95% less harmful, fulfilled the WHO FCTC Article 1 objectives, focusing on supply, demand, and harm reduction strategies.

Substantial evidence shows that Nigeria encounters significant obstacles in emulating Sweden's achievements in reducing smoking rates. Some studies show a lack of awareness among medical students and community pharmacists regarding Tobacco Harm Reduction (THR) methods and products. The media, which is pivotal in disseminating accurate information and countering misinformation about THR policies, alternatives, and benefits, also does not seem adequately educated about it. In effect, the efficacy of these approaches in Nigeria may suffer due to factors such as insufficient awareness, cultural disparities, and affordability. Consequently, healthcare professionals, including medical students and community pharmacists, must enhance their understanding of THR methods and products. Addressing cultural variations and affordability challenges is also crucial. The affordability of harm-reduction products can be a barrier to their adoption, especially in low- and middle-income countries like Nigeria. Enhancing affordability can include subsidies, tax incentives, and support for producing affordable harm-reduction products. Nigeria must consider these factors when formulating and executing THR policies and programs.

Therefore, to replicate Sweden's success in reducing smoking rates, Nigeria requires a multifaceted approach. Although the country has made progress in tobacco control, including ratifying the WHO Framework Convention on Tobacco Control and enforcing policies such as higher taxes on tobacco products, public smoking bans, and regulations on tobacco advertising and sponsorship, challenges persist, with relatively high tobacco consumption rates and a lack of awareness about tobacco harm reduction (THR) methods and products among healthcare professionals. Nigeria needs to focus on several key strategies.

First, the government should design and enforce effective tobacco harm reduction policies, ensuring access to non-combustible tobacco alternatives. These measures include regulatory frameworks, public awareness campaigns, and collaboration with the media.

Second, there is a need to strengthen knowledge among healthcare professionals and the general public about THR methods and products. This measure could involve training programs, educational initiatives, and integrating THR into existing healthcare systems. Again, promoting the affordability of harm reduction products is crucial to ensure their accessibility to the population. The call for fresh deliberations on tobacco harm reduction regulations in Africa underscores the importance of prioritizing THR as a public health strategy. By adopting harm reduction approaches and ensuring access to non-combustible tobacco alternatives, Nigeria can make significant strides in reducing the burden of smoking-related illnesses and improving public health outcomes.

Finally, Nigeria stands at a pivotal juncture, challenged to revolutionize its public health landscape by embracing Tobacco Harm Reduction (THR) products. These alternatives to smoking present a unique opportunity to diminish smoking rates and enhance public health outcomes. THR products provide smokers with a less hazardous avenue to satiate their nicotine cravings, offering a potential paradigm shift in harm reduction strategies. Unlocking the full potential of THR in Nigeria requires confronting prevailing challenges, including insufficient awareness, cultural disparities, and affordability issues.

A concerted effort is necessary, involving collaboration with the media, healthcare professionals, and policymakers. The dissemination of accurate information through the media can dispel misconceptions surrounding THR, fostering a more informed public. Engaging healthcare professionals ensures that these alternatives are integrated into the broader healthcare framework, encouraging smokers to consider THR a viable option. Policymakers play a crucial role in crafting regulations that facilitate the accessibility and affordability of THR products. By addressing these challenges collaboratively, Nigeria can pave the way for a healthier, smoke-free future, demonstrating a commitment to public well-being and global leadership in tobacco harm reduction.