In general, smoking prevalence has decreased worldwide but the number of smokers increased due to a growing population. Between 1990 and 2019, smoking prevalence has been considerably reduced in all Nordic countries (Norwegian females win with a 57.6% decrease).1 The use of alternative nicotine products, however, is another story.
Reflections from sessions on tobacco prevention and environmental factors of lung disease
Take-homes from speakers: Charlotta Pisinger (Denmark), Magnus Lundbäck (Sweden) and Cecilie Svanes (Norway),
Maintaining nicotine dependency
As smoking is no longer tolerated everywhere anytime, this means “lost occasions” from a tobacco industry’s point of view, which creates an incentive to develop complementary products to fill these gaps. Novel nicotine products, like vapes, nicotine pouches and nicotine gel, have utilized legislation loop holes (neither tobacco nor nicotine medication) and can avoid tobacco taxation and circumvent marketing or flavour bans.
A less-smoking generation with a heavy nicotine addiction
From marketing activities, it’s clear that “current smokers” are not the target group. New products, intentionally designed in bright colours and fresh flavors, marketed with free samples at music festivals and party places, attract new – and young consumers. Once hooked, many young users learn just how addictive nicotine is. A survey among Danish youths show that roughly 3 out of 4 daily nicotine pouch users have considered quitting within the last month.2 Top three reasons to quit were health, becoming free from dependency and economy. Meanwhile, the market share of high or very high strength products is growing rapidly.3,4
Extrapulmonary effects of non-inhaled nicotine
Recent research from Magnus Lundbäck and colleagues have shown that even one occasion of ecigarette use causes increased blood clotting5, arterial stiffness, and airway obstruction.6 Arterial stiffness is found in long time snus users,7 and links to an excess risk of fatal events of myocardial infarction8 and stroke.9 They also have poorer vasodialating response to nitroglycerin.7
Nicotine use in pregnancy
The popularity of white snus in young females has exploded, which, later down the line is likely to increase nicotine exposure during pregnancy. It has been shown that snus during pregnancy, just like smoking, constitutes a risk for both the mother and child10 (risk of miscarriage, premature birth, pregnancy depression, damaged blood vessels and higher blood pressure in the infant plus tripled risk of sudden infant death syndrome11). At the age of 5, children exposed to prenatal smoking present with signs of vascular damage. 12
How is non-inhaled nicotine a pulmonary concern?
Use of alternative nicotine products increase the risk of smoking initiation in young users,2,13 and using two or three products is common13. Nicotine use may also impact lung function over generations: Cecilie Svanes presented epidemiological observations linking paternal smoking in puberty to a 3-fold increased risk of offspring asthma and lower lung function, even if he quits long before conception.14 There appears to be an epigenetic mechanism behind – fathers’ smoking in puberty changes offspring DNA methylation in multiple genes linked to both asthma/wheezing and obesity.15
Way forward
Cigarette smoking is now considered universally bad for health, but it took several decades to acknowledge it and plenty of resistance from the tobacco industry. The lobbying of the novel nicotine products as “harm reduction” has paved the way for market growth. For nicotine pouches alone, the market is projected to grow from 6.9 billion dollars (2025) to 42.4 billion dollars in 2033.4
As Charlotta Pisinger pointed out, the impact of nicotine use on public health is huge, since the potential harm has to do with both degree of toxicity and number of individuals exposed.
The growing body of evidence is pointing towards a need of stronger regulation and prevention of (any) nicotine addiction – not only for the sake of the current young generation but their unborn children.
Erika Petersson
Medical Digital Content Manager, Chiesi
References
- Reitsma MB, Kendrick PJ, Ababneh E, et al. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet. 2021;397:2337–2360. doi:10.1016/S0140-6736(21)01169-7
- Arp S, Lund L, Bast LS. §RØG – en undersøgelse af tobak, adfærd og regler: udvalgte tendenser 2025, rapport 7. København: [Statens Institut for Folkesundhed, SDI]; 2026. 133 p.
- Ali FRM, Seaman EL, Crane E, Schillo B, King BA. Trends in US e-cigarette sales and prices by nicotine strength, overall and by product and flavor type, 2017–2022. Nicotine Tob Res. 2023;25(5):1052–1056. doi:10.1093/ntr/ntac284
- Grand View Research. Nicotine pouches market size & share, industry report, 2033. San Francisco (CA): Grand View Research; [cited 2026 Jun 9]. Available from: https://www.grandviewresearch.com/industry-analysis/nicotine-pouches-market-report
- Lyytinen G, Brynedal A, Anesäter E, et al. Electronic cigarette vaping with nicotine causes increased thrombogenicity and impaired microvascular function in healthy volunteers: a randomised clinical trial. Cardiovasc Toxicol. 2023;23:255–264. doi:10.1007/s12012-023-09802-9
- Antoniewicz L, Brynedal A, Hedman L, Lundbäck M, Bosson JA. Acute effects of electronic cigarette inhalation on the vasculature and the conducting airways. Cardiovasc Toxicol. 2019;19(5):441–450. doi:10.1007/s12012-019-09516-x
- Antoniewicz L, Kabele M, Nilsson U, Pourazar J, Rankin G, Bosson JA, Lundbäck M, et al. Chronic snus use in healthy males alters endothelial function and increases arterial stiffness. PLoS One. 2022;17(6):e0268746. doi:10.1371/journal.pone.0268746
- Hergens MP, Alfredsson L, Bolinder G, Lambe M, Pershagen G, Ye W. Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men. J Intern Med. 2007;262(3):351–359. doi:10.1111/j.1365-2796.2007.01816.x
- Hansson J, Galanti MR, Hergens MP, et al. Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival. J Intern Med. 2014;276(1):87–95. doi:10.1111/joim.12219
- Brinchmann BC, Vist GE, Becher R, et al. Use of Swedish smokeless tobacco during pregnancy: a systematic review of pregnancy and early life health risk. Addiction. 2023;118(5):789–803. doi:10.1111/add.16114
- Gunnerbeck A, Lundholm C, Rhedin S, et al. Association of maternal snuff use and smoking with sudden infant death syndrome: a national register study. Pediatr Res. 2023;94(2):811–819. doi:10.1038/s41390-022-02463-4
- Geerts CC, Bots ML, van der Ent CK, Grobbee DE, Uiterwaal CSPM. Parental smoking and vascular damage in their 5-year-old children. Pediatrics. 2012;129(1):45–54. doi:10.1542/peds.2011-0249
- Raitasalo K, Bye EK, Pisinger C, et al. Single, dual, and triple use of cigarettes, e-cigarettes, and snus among adolescents in the Nordic countries. Int J Environ Res Public Health. 2022;19:683. doi:10.3390/ijerph19020683
- Svanes C, Koplin J, Skulstad SM, et al. Father’s environment before conception and asthma risk in his children: a multigeneration analysis of the Respiratory Health in Northern Europe study. Int J Epidemiol. 2017;46(1):235–245. doi:10.1093/ije/dyw151
- Kitaba NT, Knudsen GTM, Johannessen A, et al. Fathers’ preconception smoking and offspring DNA methylation. Clin Epigenetics. 2023;15:131. doi:10.1186/s13148-023-01540-7
ID 22687-10.06.2026
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