Around 1.3 billion adults worldwide still smoke. Countries like Sweden are showing the world what is possible by embracing smoke-free alternatives and promoting Tobacco Harm Reduction (THR). This is the path forward to reduce tobacco-related diseases.

A smoke-free world may seem out of reach. Yet Sweden has already made it a measurable public health outcome. For most of the world, however, that milestone remains out of reach.  

Tobacco use remains one of the world’s most pressing public health challenges. The World Health Organization (WHO) estimates that tobacco causes more than 7 million deaths each year, including 1.6 million among non-smokers exposed to second-hand smoke.  

Much of this burden is tied directly to combustible tobacco use. Smoking is a major risk factor for noncommunicable diseases (NCDs), including cardiovascular disease, cancer, and chronic respiratory conditions.  

From a public health perspective, the most effective ways to avoid these risks are clear: never start smoking, or quit completely.  

Yet, despite decades of public awareness campaigns and smoking restrictions, smoking remains widespread. Around 1.3 billion adults globally still use tobacco. 

So, how should public health respond to smokers who do not quit? 

Across the world, more countries are setting smoke-free ambitions. For most, this means substantially reducing exposure to combustible tobacco smoke, not necessarily eliminating nicotine use. 

Understanding Tobacco Harm Reduction 

One approach drawing increasing attention from policymakers and public health advocates worldwide is Tobacco Harm Reduction (THR).  

THR is a public health strategy aimed at reducing health risks among adults who continue to use nicotine by encouraging a shift away from combustible tobacco products.   

The central idea is straightforward: while quitting all tobacco and nicotine use entirely remains the preferred outcome, people who would otherwise continue smoking may benefit from switching completely to lower-risk alternatives. 

This distinction matters. The largest share of smoking-related disease is linked to inhaling toxic substances produced through combustion, not nicotine use itself.  

Nicotine itself is addictive and not without risk. Current evidence suggests, however, that most serious diseases linked to smoking, including lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular complications, are primarily driven by repeated exposure to toxic smoke, not nicotine alone.  

This understanding has shaped growing interest in non-combustible alternatives. 

What Are Smoke-Free Alternatives? 

Over the past decade, a range of non-combustible nicotine products have become more widely available, including e-cigarettes (vapes), heated tobacco products, and oral nicotine products. These products are not risk-free and are not intended for non-smokers or young people.  

A growing body of research suggests that some non-combustible alternatives expose users to fewer harmful chemicals than conventional cigarettes. The Royal College of Physicians (RCP), a British professional membership body dedicated to improving the practice of medicine and one of the most respected medical institutions in the world, has stated that the health risks associated with e-cigarettes are unlikely to exceed 5% of the harm caused by smoking tobacco. 

Perhaps a key question for public health is not only reducing nicotine use, but also reducing exposure to smoke among those who continue to use nicotine. 

Sweden: A Case Study in Reducing Smoking 

Sweden is one of the most frequently cited examples in conversations around harm reduction. 

The EU has set a long-term ambition for member states to become smoke-free, commonly defined as reducing smoking prevalence below 5% of the adult population. 

In 2025, Sweden crossed that threshold. 

Data from the Swedish Council for Information on Alcohol and Other Drugs (CAN) showed that daily smoking had fallen to 3.7%, significantly below the EU average of 24%. 

Sweden’s progress did not happen overnight and cannot be attributed to a single intervention. 

Over five decades, Sweden combined traditional tobacco control measures with broader access to ​smoke-free ​alternatives ​     ​. The country has long had widespread use of snus, an oral tobacco product, and has more recently seen growing adoption of newer non-combustible products. 

At the same time, Sweden reports 39.6% lower rates of tobacco-related disease compared to the EU average. Sweden also has a lower incidence of cancer, including lung cancer, than its European counterparts. 

One study suggests that had other EU countries encouraged smokers to switch to alternative products, up to 355,000 lives could have been saved per year. 

Sweden’s experience offers a compelling example of how smoking reduction strategies can evolve alongside shifting consumer behavior. 

Expanding the Conversation 

Public health has made enormous strides in reducing smoking globally. But the reality remains that many adults continue to smoke despite knowing the risks. 

This reality raises another question. How can health systems reduce harm among those who do not quit despite knowing the risks? 

THR reflects a broader public health principle: reducing exposure to the most harmful forms of consumption can still create meaningful health gains. 

Prevention and cessation remain the priority. For those who cannot or do not stop using nicotine, however, helping them move away from smoke may be a pathway worth pursuing. 

For more information on THR and what you can do, explore our website: https://asiaharmreductionalliance.net/