Introduction
Current efforts to curb smoking are not working quickly or effectively enough. There are 1.1billion people who smoke around the world, a figure that has little changed since 2000, and 80 per cent of them live in low- and middle-income countries. Many millions of people also use other risky tobacco products. The World Health Organization’s projected death toll from smoking has not changed in 20 years and still stands at one billion by the end of the century. In 2006, the WHO forecast there would be 8 million deaths a year by 2030,[1] but we are already there.
Existing tobacco control measures are failing to reduce the death and disease caused by smoking, but there is another option available: tobacco harm reduction (THR). To those who currently use high-risk tobacco products, like cigarettes and some oral tobaccos, THR offers the chance to switch to a range of safer nicotine products (SNP) that pose fewer risks to their health. In the case of cigarettes, it is the burning of the tobacco that releases tar and gases containing thousands of harmful toxins. By contrast, SNP are non-combustible, and some of them contain no tobacco at all. To those who want to reduce the harm connected to their use of nicotine, there are now a range of safer options available, including nicotine vapes (e-cigarettes), heated tobacco products, nicotine pouches, snus and nicotine replacement therapy.
What is the evidence tobacco harm reduction works?
In our recent publication “The Global State of Tobacco Harm Reduction 2024: A Situation Report” we revealed there are already at least 144 million SNP users around the world, despite most of these products only having been developed in the last 10-15 years. Within that report we showed that safer nicotine products are increasingly substituting for combustible cigarettes in a range of countries around the world, and our research shows strong evidence of an association between an increase in SNP use and a corresponding decrease in smoking.
In this Briefing Paper, we demonstrate the evidence in favour of THR on three countries from three different continents that feature at greater length in our report. We showcase the rise of heated tobacco products in Japan, the resurgence of snus use in Norway, and the adoption of nicotine vapes in New Zealand, providing the latest data to show SNP are replacing cigarettes.
Japan and heated tobacco products
Heated tobacco products first became available in Japan in 2014, and the growth in their use over the following ten years has been remarkable. While smoking rates had been falling for decades, from a peak of 79% of men aged 20-29 years old in 1970,[2] the rise in HTP use has coincided with a significant and dramatic fall in cigarette sales.
In 2022, just eight years after they were launched as a completely new product to the market, 17.9% of men and 6% of women were using HTP.[3] Meanwhile, the number of Japanese people who smoked fell from 29.7% of men and 9.7% of women in 2016,[4] to 26.5% of men and 7.7% of women in 2022.[5]
The success of HTP is unequivocal, but the relatively modest recent fall in smoking prevalence could be explained by independent and industry-sponsored studies that reveal most HTP users in Japan also smoke cigarettes.[6][7] This is important because other research has also found that HTP use allows two-thirds of these dual users to reduce the number of cigarettes they smoke,[8] a fact that could have profound implications for public health in Japan. And another study, which further emphasises this, found the reduction in cigarette sales between 2016–2019 was five times greater than the drop between 2011–2015.[9]
Our own Global State of Tobacco Harm Reduction research, which compares sales volumes, clearly demonstrates the reduction in the number of cigarettes consumed. Using market data released in annual and quarterly reports by Philip Morris International and Japan Tobacco, the sales of individual cigarettes was around 182.34 billion units in 2015. By 2023, this had dropped 52% to just 88.1 billion units, a fall of 94.2 billion units, while the sale of the tobacco sticks used in HTP that year had risen to 72 billion units in less than 10 years.
Data Source: JTI and PMI annual and quarterly earnings reports 2014-2023
So, what is behind the success of HTP in Japan? Why are HTP substituting for cigarettes? One of the main factors is their status as a safer nicotine product. HTP devices heat the sticks of tobacco inserted into them, rather than burning them or producing smoke. This reduces users’ exposure to harmful chemicals, when compared to traditional cigarettes,[10] and peer-reviewed scientific research on both current and former adult smokers who use HTP, reveals the importance of this difference. One study found that the belief that HTP are less harmful to either themselves (90.6%) or others (86.7%) was the most important factor behind their use.[11] This was followed by personal enjoyment (76.5%), while 74.4% said HTP use was more socially acceptable than smoking cigarettes. Among current smokers, 55.1% said they used HTP in the hope they may help them quit smoking.
The Global State of Smoking Poll 2019, carried out by Global Action to End Smoking (formerly the Foundation for a Smoke-Free World), found the most common reason Japanese smokers switched from cigarettes to HTP was due to concern about the health risks to others associated with second-hand smoke from cigarettes (40%).[12] This was followed by 36% who said HTP may not be as bad for their own health, and 35% who said they could use HTP in places where smoking was not allowed.
It is also the case that Japanese people are unusually open to trying new technologies. This is one of the things that encouraged Philip Morris International (PMI) to test its IQOS product in Nagoya back in the first place, and it may be another reason why Japan has taken to these new electronic gadgets so rapidly. They are also motivated by a desire to reduce their impact on their fellow citizens, while maintaining high standards of hygiene. So, the fact HTP produce neither the smoke, smell nor ash associated with combustible cigarettes, has played a key role in the speed with which they were adopted.[13]
Another factor has been a relative lack of competition from other SNP. While permitting their sale of HTP as non-medicinal tobacco products, under the framework of the Tobacco Industries Act,[14] Japan’s government has effectively banned nicotine vapes, as no nicotine liquids or vaping devices have been approved for sale in the country. And a final point worth noting is that Japan’s government has neither opposed nor come out strongly in favour of HTP, instead, this substitution has been overwhelmingly driven by consumers’ concerns about their health and the health of others.
Norway and snus
While people have been smoking tobacco in Norway since the sixteenth century,[15] the country also has a long history with snus, a smoke-free oral product made from ground tobacco leaves that is placed under the upper lip, either in small teabag-like sachets called portion snus or loose. As the use of snus does not involve the burning of tobacco, it avoids many of the risks associated with smoking, and, for more than 200 years, Norwegians have been using it. But it wasn’t until the late 1990s, that its popularity started to grow as safer forms of the product became available.
Figures from Statistics Norway show that the increase in snus use over the last few decades has also coincided with a dramatic fall in the country’s smoking rates.[16] In 2005, 5% of Norwegians aged between 16 and 74 used snus daily. Fast forward to 2023 and the figure for that group more than tripled, to 16%, with highs in snus use of 34% among 25-34-year-old men, and 23% for women in the same age group.
In 2023, only 7% of Norwegians aged between 16 and 74 smoked daily, meaning there are now twice as many people who use snus compared to cigarettes (16% vs 7%). 12% of 55-64-year-old women, and 14% of men in the same age group, still smoke. But among younger Norwegians smoking has all but disappeared. Just 2% of women aged 16-24 and only 4% of 16-24-year-old men smoked daily in 2023. To put this into a historical context, in 1973, the first year for which data is available, 45% of men and 43% of women aged 16-24 smoked daily. There is clear evidence that snus is substituting for cigarettes.
It is worth noting that 2017 was the first year when there were more daily snus users than people who smoked cigarettes.[17] While 11% of Norwegians aged between 16 to 74 smoked cigarettes each day in 2017, the number of daily snus users was recorded at 12%. Dual use of cigarettes and snus does occur, but it has been found to be quite rare. One study revealed that while 6.8% of men used both concurrently, only 1% reported a daily consumption of both products.[18]
So, what are some of the reasons behind the substitution of snus instead of cigarettes? To start, Norway’s status as an early adopter of many of the tobacco control laws that are now increasingly common throughout Europe meant it had a head start in the fight to bring down smoking rates. The Norwegian Health Directorate states on its website that it is “considered a country with restrictive tobacco legislation”[19] and it is ranked in the top five in Europe for the robustness of its tobacco control.[20] Norway was one of the first countries to ban the advertising of tobacco products[21] then, in 2004, it became only the second country, after Ireland, to bring in a national smoking ban, meaning smoking is prohibited in both workplaces and public places.[22] Norway was also the first country to ratify the Framework Convention on Tobacco Control (FCTC), which entered into force in 2005.[23]
This increasing stigmatisation of smoking laid the groundwork for another product to step into the place of cigarettes and Norway’s long cultural association with snus meant it had the potential to fill this role. Crucially, Norway was not subject to the EU-wide ban on snus, as it is not a member state, but the rise of this SNP was only made possible thanks to innovations which made it safer and easier to use, and therefore more attractive to those who smoked. Changes to the production process in the late 1990s meant less harmful forms of snus became available. These contained lower levels of some of the major carcinogens found in cigarette smoke, such as tobacco-specific nitrosamines and polycyclic aromatic hydrocarbons. There was also a shift in the type of products on the market, with the now familiar snus pouches taking over from the loose version that came before.[24] The new form of snus didn’t require spitting, was more convenient for users, and came with a wider range of added flavours.
Research suggests that snus “emerged as a realistic alternative to conventional cigarettes because of its ability to deliver nicotine without the combustion and the toxicants in tobacco smoke, the fact that snus can be used in smoke-free places, the competitive price and the perceived potential for harm reduction”.[25] It goes on to say that “snus has contributed to a decrease in cigarette consumption through three mechanisms: as a method of smoking cessation; as an alternative product for new generations of tobacco-prone youth who otherwise would take up smoking; and as an alternative to cigarettes for smokers who are unwilling or unable to quit smoking altogether”.
Snus also delivers a similar amount of nicotine to combustible cigarettes[26] and costs less to use.[27] For many, including younger people, snus may be a more attractive option than cigarettes, as it allows discreet nicotine consumption without the smell associated with cigarettes. It can also help avoid exposure to the cold temperatures common in Norway, as snus can be used indoors, in places where smoking is banned, while those who smoke can only do so outside bars and restaurants. Ultimately, though, consumers have made the switch on their own, choosing to embrace tobacco harm reduction in a bid to significantly improve the health of themselves and those around them.
New Zealand and nicotine vapes
Aotearoa New Zealand has experienced a steady reduction in smoking rates over the past 50 years, but since the legalisation and widespread adoption of vaping products in the past decade, this decline has gathered pace.
Before 2018, the sale of nicotine-containing vaping products and e-liquids was banned in Aotearoa New Zealand under the Smokefree Environments and Regulated Products Act 1990. So, while it was legal to use vaping devices with non-nicotine-containing e-liquid, the number of people vaping was very low. Indeed, when first measured in 2015/16, daily vaping prevalence was 0.9% among those aged 15 and over.[28] This changed following the legalisation of nicotine-containing vaping products in 2018, particularly from 2020/21 onwards when vaping numbers began to increase more rapidly. By 2023/24, the prevalence of daily vaping was 11.1%, up slightly from 9.7% the previous year. This means the estimated number of daily vapers in Aotearoa New Zealand had increased from 33,000 to 480,000 between 2015/16 and 2023/24.
The growth in vaping is highlighted by the fact that it overtook tobacco smoking in 2022, according to the New Zealand Health Survey.[29] And by 2023/24, while the vaping prevalence was 11.1%, as previously mentioned, the prevalence of daily smoking among those aged 15 and over was 6.9%, down from 16.4% in 2011/12.[30] This meant there were an estimated 300,000 people smoking daily in 2023/24. And, as the chart below shows, we project that the gap between the number of people vaping and those smoking will widen.
Taking a deeper dive into the data, it has been shown that the rise in vaping rates among Maori and Pacific Peoples has far outpaced the increase in vaping among other ethnic groups in Aotearoa New Zealand, with 27.7% of Maori and 21.7% of Pacific Peoples reporting current vape use in 2022/23.[31] This is a significant increase since the legalisation of vaping, with the proportion of Maori and Pacific Peoples who were vaping daily more than quadrupling between 2019/20 and 2022/23, compared to overall vaping rates which doubled over the same period.[32] Between 2018/19 and 2022/23, the current adult smoking rate among Maori dropped from 33.4% to 20.2%.[33] More striking is the sudden drop in smoking rates among Pacific Peoples, with the number of people currently smoking in this community more than halving between 2018/19 and 2022/23, dropping from 24.7% to 10.3%.[34]
But what are the reasons behind vaping replacing and substituting for cigarettes in Aotearoa New Zealand? A significant role has been played by the government, first through its legalisation of nicotine vaping products, and secondly via the way it has provided positive messaging around their potential value for public health. As part of the country’s ambition to be smokefree by the end of 2025 (meaning smoking prevalence is less than 5%), the Ministry of Health has highlighted the role of vaping in helping smokers quit and has provided official resources for people looking to stop smoking with the help of vaping. Smokefree New Zealand, a smoking cessation resource run by the country’s publicly funded healthcare service Health New Zealand, has stated that “using vaping products is a legitimate option for those people who are trying to quit smoking”.[35] The Ministry of Health of New Zealand and Health New Zealand, through the Vaping Facts website,[36] have also emphasised the Cochrane review’s position that vaping is significantly safer than smoking,[37] with particular focus on the fact there is no combustion when using a vaping product and that dual use of vaping products and combustible tobacco can be a valid part of an individual’s journey to smoking cessation.[38]
And what are some of the reasons given by people in the country who have taken to using vapes? A representative survey of current and ex-smokers who participated in the International Tobacco Control (ITC) New Zealand Surveys found the primary reason for using vaping products was the incentive to save money compared to tobacco smoking, followed by the desire to cut down on smoking, and the desire to quit smoking.[39]
Key takeaways
Japan, Norway and New Zealand show how dramatically smoking rates can fall when safer alternatives are made readily available. In less than a decade, we have witnessed a major, global transformation in the way that nicotine is consumed, from a mechanism that kills over half of its users to the emergence of safer alternatives which pose a fraction of the harm. This shows every sign of continuing and is largely driven by smokers themselves.
The strong evidence that safer nicotine products are replacing cigarettes should be welcomed. Indeed, there are countries where SNP use has now overtaken cigarettes. The example of Japan, where an internationally unprecedented decline in the sale of combustible tobacco has occurred, illustrates how quickly positive change can be achieved when regulations do not hamper progress. In many countries the availability of SNP is making a hugely significant contribution to achieving their target of being smoke free (smoking prevalence below 5%).
The factors supporting these public health gains appear to be more about the availability of acceptable and affordable products, coupled with consumer interest, rather than active governmental or public health interventions. If governments, public health bodies and health agencies actively supported the move to safer products, the global potential for more rapid declines in smoking rates, and the accompanying improvements in health, can only be imagined.
For further information about the Global State of Tobacco Harm Reduction’s work, or the points raised in this GSTHR Briefing Paper, please contact [email protected]
About us: Knowledge·Action·Change (K·A·C) promotes harm reduction as a key public health strategy grounded in human rights. The team has over forty years of experience of harm reduction work in drug use, HIV, smoking, sexual health, and prisons. K·A·C runs the Global State of Tobacco Harm Reduction (GSTHR) which maps the development of tobacco harm reduction and the use, availability and regulatory responses to safer nicotine products, as well as smoking prevalence and related mortality, in over 200 countries and regions around the world. For all publications and live data, visit https://gsthr.org
Our funding: The GSTHR project is produced with the help of a grant from Global Action to End Smoking (formerly known as Foundation for a Smoke-Free World), an independent, US non-profit 501(c)(3) grant-making organisation, accelerating science-based efforts worldwide to end the smoking epidemic. Global Action played no role in designing, implementing, data analysis, or interpretation of this Briefing Paper. The contents, selection, and presentation of facts, as well as any opinions expressed, are the sole responsibility of the authors and should not be regarded as reflecting the positions of Global Action to End Smoking.
[1] Colin D. Mathers and Dejan Loncar, ‘Projections of Global Mortality and Burden of Disease from 2002 to 2030’, PLoS Medicine 3, no. 11 (November 2006): e442, https://doi.org/10.1371/journal.pmed.0030442.
[2] Funatogawa, I., Funatogawa, T., & Yano, E. (2013). Trends in smoking and lung cancer mortality in Japan, by birth cohort, 1949–2010. Bulletin of the World Health Organization, 91(5), 332–340. https://doi.org/10.2471/BLT.12.108092, pp. 1949–2010.
[3] Odani, S., & Tabuchi, T. (2022). Prevalence and denial of current tobacco product use: Combustible and heated tobacco products, Japan, 2022. Preventive Medicine Reports, 30, 102031. https://doi.org/10.1016/j.pmedr.2022.102031.
[4] Japan Tobacco Inc. Japan Tobacco Inc. Japan smoking rate survey, 1965–2018. Japan Health Promotion & Fitness Foundation, 2018. http://www.health-net.or.jp/tobacco/product/pd090000.html (accessed 16 Dec 2019).
[5] State of Smoking and Health in Japan. Global Action to End Smoking, 2025. https://globalactiontoendsmoking.org/research/tobacco-around-the-world/japan/
[6] Kubota, T., Minami, N., Kimura, Y., & Kakehi, A. (2019). Use behaviour patterns in Japanese novel tobacco vapour product (NTV) users. CORESTA. https://www.coresta.org/abstracts/use-behaviour-patterns-japanese-novel-tobacco-vapour-product-ntv-users-32852.html.
[7] Sutanto, E., Miller, C., Smith, D. M., O’Connor, R. J., Quah, A. C. K., Cummings, K. M., Xu, S., Fong, G. T., Hyland, A., Ouimet, J., Yoshimi, I., Mochizuki, Y., Tabuchi, T., & Goniewicz, M. L. (2019). Prevalence, Use Behaviors, and Preferences among Users of Heated Tobacco Products: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 16(23), 4630. https://doi.org/10.3390/ijerph16234630.
[8] Xu, S. S., Meng, G., Yan, M., Gravely, S., Quah, A. C. K., Ouimet, J., O’Connor, R. J., Sutanto, E., Yoshimi, I., Mochizuki, Y., Tabuchi, T., & Fong, G. T. (2020). Reasons for Regularly Using Heated Tobacco Products among Adult Current and Former Smokers in Japan: Finding from 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(21), 8030. https://doi.org/10.3390/ijerph17218030.
[9] Cummings, K. M., Nahhas, G. J., & Sweanor, D. T. (2020). What Is Accounting for the Rapid Decline in Cigarette Sales in Japan? International Journal of Environmental Research and Public Health, 17(10), 3570. https://doi.org/10.3390/ijerph17103570.
[10] Opinion: Heated tobacco - a new review looks at the risks and benefits. University College London, 2022. https://www.ucl.ac.uk/news/2022/jan/opinion-heated-tobacco-new-review-looks-risks-and-benefits
[11] Xu, 2020
[12] Global State of Smoking Poll, Japan. (2019). Foundation for a Smoke-Free World. https://www.smokefreeworld.org/wp-content/uploads/2020/03/Global-State-of-Smoking-Poll-2019-_-Japan-Final-Report.pdf.
[13] The story of THS in Japan, an interview with Tomoko Iida. (2022, October 24). PMI Science. https://www.pmiscience.com/content/pmiscience/language-master/en/news-events/scientific-update-magazine/the-story-of-ths-in-japan--an-interview-with-tomoko-iida-.html. (accessed in 2023)
[14] Act No. 68 of 1984. Tobacco Business Act. https://elaws.e-gov.go.jp/document?lawid=359AC00000000686.
[15] Larsen, I. F. (1997). [Smoking and art. History of smoking in Norway in paintings]. Tidsskrift for Den Norske Laegeforening: Tidsskrift for Praktisk Medicin, Ny Raekke, 117(30), 4418–4421.
[16] Tobacco, alcohol and other drugs. (2024, January 18). Statistisk Sentralbyrå (Statistics Norway, SSB). https://www.ssb.no/en/helse/helseforholdog-levevaner/statistikk/royk-alkohol-og-andre-rusmidler.
[17] Snus more used than cigarettes. (2018, January 18). Statistisk Sentralbyrå (Statistics Norway, SSB). https://www.ssb.no/en/helse/artikler-ogpublikasjoner/snus-more-used-than-cigarettes.
[18] Lund, K. E., & McNeill, A. (2013). Patterns of Dual Use of Snus and Cigarettes in a Mature Snus Market. Nicotine & Tobacco Research, 15(3), 678–684. https://doi.org/10.1093/ntr/nts185.
[19] Tobacco Control in Norway. (2023, August 23). Helsedirektoratet. https://www.helsedirektoratet.no/english/tobacco-control-in-norway.
[20] Joossens, L., Olefir, L., Feliu, A., & Fernandez, E. (2022). The Tobacco Control Scale 2021 in Europe. Tobacco Control Scale. https://www.tobaccocontrolscale.org/.
[21] Rimpelä, M. K., Aarø, L. E., & Rimpelä, A. H. (1993). The effects of tobacco sales promotion on initiation of smoking—Experiences from Finland and Norway. Scandinavian Journal of Social Medicine. Supplementum, 49, 5–23.
[22] Key Dates in Tobacco Regulation 1962—2020. (2022, April). ASH. https://ash.org.uk/resources/view/key-dates-in-tobacco-regulation.
[23] Tobacco Control in Norway, 2023.
[24] Grøtvedt, L., Forsén, L., Ariansen, I., Graff-Iversen, S., & Lingaas Holmen, T. (2019). Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway. BMC Public Health, 19(1), 1265. https://doi.org/10.1186/s12889-019-7584-5.
[25] Lund, I., & Lund, K. E. (2014a). Lifetime smoking habits among Norwegian men and women born between 1890 and 1994: A cohort analysis using cross-sectional data. BMJ Open, 4(10), e005539. https://doi.org/10.1136/bmjopen-2014-005539.
[26] Foulds, J., Ramstrom, L., Burke, M., & Fagerstrom, K. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 12(4), 349–359. https://doi.org/10.1136/tc.12.4.349.
[27] What is snus and why do so many Norwegians use it? (2021, June 28). The Local Norway. https://www.thelocal.no/20210628/what-is-snus-andwhy-do-so-many-norwegians-use-it.
[28] Trends in smoking and vaping: New Zealand Health Survey. The Ministry of Health – Manatū Hauora. New Zealand Government, 2024. https://www.health.govt.nz/statistics-research/surveys/new-zealand-health-survey/publications/202324-survey-publications/trends-in-smoking-and-vaping.
[29] Annual Data Explorer 2022/23: New Zealand Health Survey [Data File], 2023.
[30] The Ministry of Health – Manatū Hauora. New Zealand Government, 2024.
[31] Annual Data Explorer 2022/23: New Zealand Health Survey [Data File], 2023.
[32] Nip, J., Hoek, J., & Waa, A. (2023). Vaping prevalence and trends: Key findings in the 2022/23 NZ Health Survey. Public Health Expert Briefing. https:// www.phcc.org.nz/briefing/vaping-prevalence-and-trends-key-findings-202223-nz-health-survey.
[33] Annual Data Explorer 2022/23: New Zealand Health Survey [Data File], 2023.
[34] Annual Data Explorer 2022/23: New Zealand Health Survey [Data File], 2023.
[35] Learn about vaping. (2023). Smokefree. The National Public Health Service’s Health Promotion Directorate. Te Whatu Ora | Health New Zealand. https://www.smokefree.org.nz/help-advice/learn-about-vaping.
[36] Our position on vaping. Manatū Hauora (Ministry of Health), Te Whatu Ora and Te Aka Whai Ora are supported by a number of organisations in their position on vaping. (2022). Vaping Facts. Te Whatu Ora/Health New Zealand. https://vapingfacts.health.nz/our-position-on-vaping.html.
[37] Risks of Vaping. (n.d.). Vaping Facts. Te Whatu Ora/Health New Zealand. Retrieved 26 September 2024, from https://vapingfacts.health.nz/thefacts-of-vaping/risks-of-vaping/.
[38] Te Whatu Ora, Health Promotion (Director). (2023, October 18). Vaping, what the doctor says Original. https://www.youtube.com/watch?v=UjhITheN9I0.
[39] Edwards, R., Stanley, J., Waa, A. M., White, M., Kaai, S. C., Ouimet, J., Quah, A. C. K., & Fong, G. T. (2020). Patterns of Use of Vaping Products among Smokers: Findings from the 2016–2018 International Tobacco Control (ITC) New Zealand Surveys. International Journal of Environmental Research and Public Health, 17(18), 6629. https://doi.org/10.3390/ijerph17186629.