Science of harm reduction: What the Middle East can learn from Sweden

Alexandre Ghanem GM MENA at British American Tobacco (BAT)

Tobacco use remains a major public health challenge across the Middle East. In seven countries often grouped for regional analysis – Egypt, Pakistan, Jordan, Lebanon, Kuwait, Saudi Arabia, and the UAE – about 61 million adults were reported consumers of tobacco products in 2024, out of a combined population of roughly 390 million. Within this context, cigarette smoking remains both deeply ingrained and a leading public health challenge.

WHO projections also indicate only a modest decline in smoking prevalence in the region through the mid-2020s, underscoring the need to complement existing tobacco-control measures with pragmatic tools that can reduce the public health burden of smoking. Such burden is often seen at its highest in low and middle-income countries, where traditional cessation methods fail to support most smokers. This is precisely why risk-proportionate harm-reduction strategies are becoming increasingly discussed as an equity issue in public health.

Harm reduction as a pillar of tobacco control

Tobacco harm reduction (THR) refers to policies and tools that aim to mitigate the adverse health effects associated with continued smoking by encouraging adult smokers who would not otherwise quit, to switch completely to smokeless alternatives with a reduced-risk profile. THR, underpinned by science-led innovation, can help reduce the population level harm associated with using tobacco.

Evidence from countries, such as Sweden, show that offering potentially reduced-risk smokeless alternatives can accelerate declines in smoking and relieve pressure on health systems.

Understanding the risk profile of smokeless products

Recent commentary in the Middle East has asserted that tobacco-free oral nicotine pouches contain numerous harmful substances and implied equivalence with smoking-related risks. However, the weight of evidence points in a different direction, underscoring the need for communications to highlight the relative risk profile of smokeless products compared with smoking, so that adult consumers receive accurate and actionable information.

Across the range of such products, tobacco-free oral nicotine pouches have emerged as particularly promising for adult smokers who would otherwise continue to smoke, offering a pathway to switch to smokeless alternatives.

These alternatives do not claim zero risk – no nicotine product is risk-free – but they do show relative risk reductions compared with continued smoking. What drives the difference? Risk tracks with exposure to smoke, not nicotine itself. Products that avoid combustion reduce exposure to smoke-borne toxicants.

This has been acknowledged by the UK Government Committee on Toxicity, who have stated that using  tobacco-free oral nicotine pouches which are produced according to appropriate manufacturing standards and used as recommended “as a replacement for [conventional cigarettes] smoking, would be associated with a reduction in overall risk of adverse health effects…”.

Primarily, leading health bodies separate nicotine from combustion in assessing major health risks, noting that nicotine itself (i) is not a carcinogen; and (ii) does not contain toxic chemicals found in cigarettes. Second, at the population level, countries with high uptake of smokeless alternatives have seen sharply better health outcomes than their peers with similar nicotine exposure but higher cigarette consumption.

Furthermore, switching from cigarettes to smokeless alternatives, such as tobacco-free oral nicotine pouches, is also associated with better day-to-day oral health markers. These range from improved gum condition, reduced bacterial plaque, healthier mucosal vascularisation, increased salivary flow, and normalised breath compared with continued smoking.

Multi-country research is now quantifying these effects at scale: the SMILE trial across Italy, Poland, Moldova, and Indonesia is tracking changes in tooth colour, plaque and gingival health in adults who switch to smokeless alternatives for nicotine delivery, expecting measurable improvements in oral aesthetics and gum status.

The reduced risk profile of such pouches is further complemented by the fact that they have been adopted and are in use in 40 plus countries, offering a non-combustible, socially considerate format that avoids smoke and second-hand exposure.

Sweden’s smoke-free trajectory

Sweden is a best-practice example of how switching away from cigarettes can fundamentally reshape public health trends. Sweden has long embraced a risk-proportionate approach to smokeless alternatives, notably with tobacco-free oral nicotine pouches, which have widely been recognized as a lower-risk profile alternative for nicotine use by several government bodies and members of the public health community.

This is reflected in the fact that Sweden’s cancer incidence is 41% lower than the European average, with a corresponding 38% lower rate of total cancer deaths – underscoring the effectiveness of a THR-centred policy approach.

In fact, the country’s adult smoking rate is now about 5.3% – the lowest in Europe – and has fallen 54% over 12 years, driven by the widespread use of smokeless products, with daily use among adults standing at roughly 15.7%.

A practical path forward for the Middle East

The imperative is clear: regulate to protect youth, communicate risk proportionately, and ensure adult smokers have access to reduced-risk profile alternatives. In a region with tens of millions of smokers, the public-health opportunity is significant.

For Middle Eastern regulators faced with high health risk burdens, THR offers a complementary policy pathway that supports reductions in smoking rates and associated harms. As the Swedish experience suggests, when adult smokers have affordable, acceptable, and reduced-risk profile alternatives, smoking prevalence drops, quitting rates rise, and disease indicators improve.

By looking to best practices worldwide, the region can adopt a similar approach to reduce the health burden associated with combustible tobacco use.