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Brent: Hi, I'm Brent Stafford, and welcome to another edition of Reg Watch on GFN.TV. Technological innovation. It's the lifeblood of economic growth and advancement in health and wellbeing. Over time, countless products found to be hazardous to health, have undergone a reinvention, becoming much safer to use than the product they replaced. Only two decades old, nicotine vaping products are one such example of technological innovation. Vaping has the potential to eradicate combustible tobacco, saving millions of lives. But surprisingly, there's another, safer nicotine product which is also wildly popular. Yet it could hardly be called new. That product is called Snus. It's hundreds of years old and responsible for crashing smoking rates in its home country, Sweden. Joining us today to discuss the momentous struggle for safer nicotine products is Cecilia Kinstrand Isaksson, director of Public Affairs at Swedish Match. Swedish Match is the globally dominant manufacturer and distributor of Snus, a smokeless tobacco product taken orally via a pouch placed under the upper lip. In Sweden, Snus is credited for sharp declines in smoking, delivering the lowest male smoking rate in all of Europe. Cecilia, thanks for coming on the show.

Cecilia: Thank you very much for having me.

Brent: Let's start with a bit more explanation. What exactly is Snus and how long has it been around?

Cecilia: Snus is a tobacco product. It's been around for a very long time. In Sweden or in the wider Scandinavian countries, it's tobacco in a pouch, predominantly used in a pouch today, the pouch is a fairly new invention. It came around in the 1970s. Before that, people took Snus in its loops format. They took a pinch and placed it in their mouth. And the pouch, I would say, is responsible for the popularity of the product, because before you had it in a small pouch or a tea bag, it wasn't very attractive. But the pouch in itself helped the product to become more popular. The tobacco is pasteurized, as opposed to chewing tobacco, which is fermented. The pasteurization is an old story, but by pasteurizing the product, you're also having a more stable climate in the product.

Brent: Now, what's the difference between Snus and, say, a nicotine pouch?

Cecilia: Snus contains tobacco and nicotine pouch doesn't contain tobacco. That's at least the difference in the European Union legislation or in the EU legislation. In other jurisdictions, nicotine pouches are silliness tobacco products because the nicotine is tobacco derived. But in the EU or in Europe in general, it's not silliness tobacco product.

Brent: Now, are they both considered safer nicotine products, then?

Cecilia: I think it's fair to say that they are. If you compare to cigarettes, not perhaps if you compare to nicotine replacement therapies, but definitely compared to combustible tobacco, they are considered much safer, both of them.

Brent: Now, tell us about your company, Swedish Match. Did or do you still sell cigarettes?

Cecilia: No, we don't. We divested the cigarette business in 1999, quite some time ago. My company is very committed to harm reduction and we have a vision, which is a world without cigarettes. It's almost ten years old now, and our company recognized that in order to provide or create shareholder value, we wanted to sell products that are actually good, better than other products in the same category, in the wider tobacco category. But the company as such, we have a long history of harm reduction in terms of what we've done with, with the product over time.

Brent: I would imagine that you were one of the originators in that.

Cecilia: Yeah, in the 80s or 90s we had a very interesting CEO, Stefan Gelkner. And at that time, Snus is a very small product on the market at that point. But it was felt within the company that the Snus product that people put in their mouth shouldn't be more toxic than normal food staff. So we invested quite a lot of money into a standard with the guilty attack standard. So it's our own standard and there are requirements on where you can grow the tobacco, how you should treat it afterwards. We went from smoke cured tobacco to air or sun cured tobacco. And by that we eliminated levels of we almost eliminated all the ben spirants, for example, that were in the product before. And we have limits on unwanted constituents in the product, which is if you compare to normal food, it's significantly less.

Brent: In some of the documentation that I've seen with regard to your product, it says that there is very little or no NNN and TNN, which are normally toxic ingredients inside of a cigarette. I'm not actually familiar after all these years covering this issue, I'm not familiar with those. Could you tell us a little bit more about that?

Cecilia: So I think you're talking about the TSNAs, the tobacco specific neutrosamines, which are tobacco specific and they are seen as carcinogens. And what we did was to eliminate them as much as we possibly could. With the GothiaTek standard, if you look at the toxicity of the Snus product, you have the ben spirits and the tobacco specific nitrosamines. These are the sort of crucial toxicants that you want to eliminate as far as possible. But then we also of course, covered other constituents that you get in everything that it's picked up by the soil. So you get it in tomatoes and in rice. So we have a number of constituents that we keep track on and that we have maximum levels that is permitted to use in our Snus products.

Brent: Let me ask you, how much safer is Snus, say, than smoking?

Cecilia: That's a debate. People have suggested 95% less harmful. I've also seen up to 99% less harmful. I have never seen really good continuum of risk, but I think it's fair to say that Snus is on the other end. If you compare the cigarettes, definitely. But it does a more toxicants than than for example, nicotine pouches, which are doesn't have any organic material to talk about.

Brent: So over the course of time, Snus has been around, as we've discussed here, for some time, many, many decades in the modern era. So what type of science is out there with regard to Snus? And have they found any problems with it that should be concerning?

Cecilia: Snus has been around, as you say, for hundreds of years. There has been quite a lot of good data coming out from Sweden because we tend to track people when it comes to their health issues. There's quite a lot of different studies around the use of Snus in Sweden, and this is probably one of the most researched tobacco products in the world. We know that people have been using it for decades in Sweden. There is data around that. So we actually have quite a good number of public health studies. So the real outcomes of what happened when people are using the product or have been using the product.

Brent: What effect has Snus had then on smoking rates in Sweden and in other countries where it's available?

Cecilia: The fact that there has been a reduced risk alternative available on the market has led to people smokers starting to use the product instead of smoking. It's also led to people not starting to smoke. And I think this is interesting, and it's difficult to argue with public health around this because of course, it's very useful if people start using Snus instead of smoking. But it's also very good if people don't start smoking at all. But they might want to use nicotine, and I would argue for public health much better to start using a less harmful product than a cigarette.

Brent: I'm just a bit discombobulated. A company that is in the business of selling nicotine delivery systems is saying that it might be okay to use nicotine.

Cecilia: I think I wouldn't want my children to use nicotine, but if they would, I would feel much better if they use the reduced risk alternative than if they started to smoke.

Brent: So, looking at some of the data, Cecilia, with regard to smoking rates, it seems that there has been a crash in smoking rates in Sweden, and I think in Norway too, as well. One of the things that the data shows is that that crash is higher with men than with women. Could you talk about that effect and what's going on there?

Cecilia: In Sweden, the product is predominantly used by men. That's not really the case in Norway. We're neighboring countries. But traditionally Snus has been seen as a very sort of male product, whereas in Norway it's more seen as a unisex product. And that's why you see more women using the product in Norway than in Sweden. It's also fair to say that the Snus used since Sweden started way earlier than in Norway. It's been around on the market. The pouch came in the 70s, it's been around in Norway. The Norwegian experience only really started maybe 20 years ago around there. And what you've seen is a rapid decline in smoking prevalence in Norway. In Sweden, we were on our way down, but Norway is almost catching up with us in terms of smoking prevalence.

Brent: Data, in terms of health outcomes. Is there any correlation with a cancer decline?

Cecilia: If you look at the statistics, swedish men has less of the traditional tobacco related cancer forms. That's not the same for women, because women smoke as their European sisters, whilst the Swedish men do not smoke like their European brothers.

Brent: Cecilia, with such great news about Snus products, smoking rates and health outcomes, I imagine the result in Europe, you know, the public health and the regulators, they must be clamoring to bring Snus to their people.

Cecilia: You would think so, but that's of course not the case. As you know, Snus is a banned in the European Union. Sweden got an exception when we joined in 1995. It was a big issue for the Swedes, and it was one of the key points in the referendum campaign leading up to the referendum that took us into the European Union. You would think that if European regulators really are keen to address issues around smoking related mobility and mortality, that they would look at all options available, but they're not too keen on alternative products.

Brent: So we have a safer nicotine product, one that's got some very strongly proven health benefits, and it works, but yet you can't get Snus anywhere. What nicotine pouches too? Is there any difference, or is it just all banned?

Cecilia: According to European legislation, nicotine pouches are not regulated under the Tobacco Products Directive. So different member states treated the product differently. Some member states have put them under their tobacco legislation. Some of them view them as a consumer product, other countries view it as a food product, and other countries also see it as a pharmaceutical product. So it's all over. We expect that there will be some sort of harmonization on the market once the Tobacco Product Directive is under revision. We will see what the details of that regulation is. But I think that's fair to say that that's most likely likely outcome. Snus of course I would bet money on that, it will still be banned because they do not want that product on the market. Because they don't want another tobacco product on the market. They don't want to have new tobacco products on the market. And I think we should also remember that the European Commission and some of the member states, they really wanted to ban e-cigarettes. When the first draft directive came out in 2012, there was a de facto ban on e-cigarettes in the proposal. This was later changed by the European Parliament predominantly. But if the Commission had gotten its will, you wouldn't have had vaping products on the European market, which would have been disastrous for public health, considering the people actually switching from smoking to vaping.

Brent: And that does bring me to my next question. You guys are road warriors when it comes to safe nicotine products and tobacco harm production. What did you first think when Vaping products came on the scene?

Cecilia: I guess we were sort of figuring out what Vaping was. But we also understand that it's not all product, not one product will fit all people, all smokers. And our strong belief in the company is that whatever alternative product the smoker needs to switch, that's the best product for them. Obviously we are a bit biased in favor of our own products, but we do acknowledge the fact that the more alternatives they have, the better.

Brent: Let me ask you, Cecilia, when did Swedish Match start using the term tobacco harm reduction?

Cecilia: It's sort of ingrained in our culture, in our company culture for a long time. I think it started being present as a notion in the company already before we started to do before we started with the GothiaTek development. Since we had adopted the company, the corporate vision, a world without cigarettes, it's becoming more clear what kind of company we are. But we have divested the cigarettes, we have spent money and resources to develop this GothiaTek standard. We're making the product as safe as possible. So it's always been there. It might not have been explicit, but there's always been a will within the company to ensure that we have a high level of protection or consumer protection.

Brent: So how do you find public health researchers, universities, regulators? Are they acceptant of tobacco harm reduction as a strategy in Europe? Because I imagine you must have had a lot of experience with anti-smoking pressure groups.

Cecilia: I think there's a fair bit of really good scientists out there. I believe that the debate has become a bit more balanced since the Vaping products came on the scene because before you only had the Swedish experience. Those crazy people in the north, no one really cared about that. But now it's more of a household concept. Safer nicotine products, of course you still have quite a lot of opponents and it's fair to say that anti tobacco movement started for good reasons. People did smoke and people were suffering from smoking. But I can't really understand why there are many people in the tobacco control world that's not willing to engage in the discussion around the benefits of alternative products. I guess that it might be because they feel that people shouldn't use anything at all. And if you believe that that's achievable, I guess you're on the right track. We're trying to remove as many alternative products as possible. But if you think that that might be a bit far fetched, the best thing for public health would be to try to get people away from the most harmful to the least harmful. I think that it seems logical to me, but I understand that that's not the point of a lot of people in the tobacco control community.

Brent: Is their position that they take and the tactics that they deploy. Are they fair or are they somewhat maddening?

Cecilia: We have the science around snows. It's quite clear today. We know the science around snows, but you've seen a lot of science coming out around Vaping, which is not necessarily helpful. I think it's also the fact that they misrepresent the risk, or the risk is misrepresented in media is the problem. If people think that Vaping or Snus use or anything else of the reduced risk alternatives, if they believe that that's equally bad as cigarettes, that's not really useful from a public health perspective. If people believe that they can continue smoking and if they would start vaping, it would be the same as smoking. That's bad, considering the vast difference in risk between cigarettes and e-cigarettes or cigarettes and Snus, or cigarettes and nicotine pouches. And of course, also, I have to add, the product does contain nicotine. It is addictive or dependency forming, depending on where you stand. But of course, I think we have to be open about the fact that it does contain nicotine, which is addictive substance.

Brent: Cecilia, when we first started covering this issue around nicotine vaping products, we had no idea something like Snus existed. And I'd say for the first five years, we get the odd ping from somebody in Europe going, how come you're not covering Snus? And I'm like, what are you talking about? It's not available in Canada. I understand that some products are in the US. But it's not a product that rings in North America. And of course, Vaping is where it's at. But however, it was Dr. Brad Rodu in some of our conversations and our early coverage with him. He was like, oh, yeah, well, you really should pay attention to what's going on as Snus. And it turns out that every single argument that tobacco control has made attacking e-cigarettes and making some headway whether that's dual use, gateway now nicotine, harms teens, developing brains, all those kinds of stuff originally were battles that were fought around Snus.

Cecilia: Yeah, I guess they're using the same playbook as they used on Snus. I think it's fair to say that there is a gateway, but there's a gateway out of cigarettes. It's not a gateway into cigarettes. There's no studies, as far as I know, that shows that people are starting to use Snooze and then they go on to smoking. I guess that's the same for Vaping products as well. Dual use. What's the problem with dual use? If you start off with smoking and substitute some of your cigarettes with a reduced risk alternative, what's wrong with that? Especially because I think we know that a lot of people start out that way, and then they leave the cigarettes behind for good, and that should be a good thing.

Brent: So is there something essentially bad about having a recreational nicotine habit? If that nicotine is delivered in a safe manner.

Cecilia: I would argue no, but I guess for many people it is a problem. I think we have to recognize the fact that some people are struggling with their nicotine dependency or nicotine addiction, but there's a lot of products on the market which creates dependencies or addiction. There's a lot of products that are I think that's just the nature of society. You have a lot of products: processed food, gambling, that are not necessarily seen as necessary, but it will use them and enjoy them, and that's why you can counterbalance a lot of the potential negative consequences of it with the good regulation.

Brent: But Cecilia, what about save the kids? Don't you want to save the children?

Cecilia: Of course I do, but there are many aspects of saving the children. One is, do you want the children's parents to smoke, or do you want to offer the parents an alternative which is less harmful? I think that would be saving the children. Of course, children shouldn't use substances for grown up people. They shouldn't drink, they shouldn't smoke, they shouldn't use nicotine in any shape or form. I think you can protect them quite a lot with good regulation. I think when it comes to tobacco and nicotine, it's fair to have age limits in the same way that you have radical, for example, us as an industry, we have a responsibility to ensure that we are actually communicating in a good way with our consumers. And our consumers are not the children. It's not the kids.

Brent: Cecilia, it sounds like Snus is the first reduced risk product before anyone even knew that there was such a thing as reduced risk products. And this is going to come as a surprise to many of our viewers. In 2019, the US FDA authorized the marketing of products to Swedish Match for eight of your products under the General brand and permission was granted to communicate to the public, to the US public, that using general Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema and chronic bronchitis. What does this mean to have earned all these authorizations?

Cecilia: I think it's a testament to the quality of Snus. It's a testament to the public health data that we have around the product. It's a testament to the Swedish experience. It's extremely interesting that while the European Union is banning the product, the US authorities have stated that this is a modified risk product. So far, we are the only ones that gotten a modified risk order from the FDA. And it's a testament to the impact of Snus on public health in Sweden, then, I don't believe that Snus is a particularly popular product in the US. It is available, but it's not really perhaps what everyone use, but it's there and we have the water. So I think that's a very positive thing.

Brent: Well, certainly it is. Each and every single one of those diseases are the major killers from smoking.

Cecilia: It is the order or the claim that we're allowed to make doesn't really necessarily quantify how much reduced risk it is, but it's saying it's less risk. So that's a good start, at least in communication with our consumers.

Brent: So are you able to put that messaging in a public ad?

Cecilia: As far as I understand, we're allowed to do that.

Brent: And then what about on your packaging?

Cecilia: As far as I understand, we're not allowed to put it on the packaging, which is a bit confusing, perhaps.

Brent: So do you have to keep using the ubiquitous cancer warning?

Cecilia: Again, US legislation is not my area of expertise, but as far as I understand, the warning labels on the can stay, but we are allowed to communicate the claim that FDA has granted us.

Brent: That is what every single company involved in the Vaping business in Canada and the US is dying for.

Cecilia: Yeah, no, it's a testament to our long history, perhaps. And also the data. We have a lot of data, of course, because Sweden has covered smoking and Snus or tobacco use over time. So it's a testament to that, and it's very positive. But it doesn't necessarily mean that people will use the product.

Brent: Well, at least it'll mean that you won't be forced as a company to continue lying to your customers.

Cecilia: We are allowed to communicate truthfully. Yes.

Brent: Well, that is amazing. So what did the opponents to safer nicotine products say when FDA granted these authorizations?

Cecilia: I wasn't really a part of the process myself, but I believe that there were some representatives from Public Health who weren't super happy around the order we got. And again, I believe that that's because they feel that people shouldn't use any product at all. And then you have to see if you as I said, if you believe that that's possible, they have they might see this modified risk holder as a problem. If you believe that people will continue to use nicotine and tobacco, I would argue that the order is a step in the right direction, definitely.

Brent: Now, I would imagine that FDA's marketing authorization here is one of the reasons why. This past May, Philip Morris International made an offer of $16 billion US to buy Swedish Match. As of this recording, it looks like the purchase is going through. What can you say about that acquisition and what could it mean regarding the tobacco endgame?

Cecilia: I can't really talk about it that much. It's a deal between the owners of the company and the buyers of the company. But fair to say is that as we know today, PMI will take a very big share of my company. We do share similar visions. And for Swedish Match, being a fairly small company, I believe that we will be able to take our superior products and put them on more market to get even more smokers, to switch from smoking to our products.

Brent: And talk a little bit for us here as we're ramping up about the tobacco end game. What does that mean and how does Swedish Match play a big role in it?

Cecilia: Well, the tobacco end game is, I guess, the WHO goal below 5% daily smoking. We have achieved that in Sweden years ago. You're on a good path towards the tobacco end game also in no way, especially if you look at specific cohorts of people, if you look at women 16 to 24, you have 1% smoking prevalence. So young and Norwegian women are not smoking. The tobacco end game will only be achieved, I believe that if smokers are offered viable, attractive products instead of cigarettes and that's the way Sweden managed to achieve the tobacco game. And I hope that the tobacco end game will be achieved in many other countries as well. But it's not going to happen with only tobacco control efforts. It has to be complemented also with a bouquet of different alternative products.

Brent: Yeah, well, then let's just hope that tobacco control doesn't move the goalpost and argue for, say, vaping zero or nicotine zero.

Cecilia: I think there's a tendency already that we're seeing that tobacco control seems to be one to equate cigarettes with reduced risk alternative and the goal will be for people to stop using tobacco and nicotine altogether instead of focusing on the harms of smoking.