This last section of the report will wrap up, discuss, and provide some overall perspectives of the development in nicotine product use and regulations across the Nordic and Baltic countries.

The report presents an illustration and overview of the current status for each country.  When comparing current trends in nicotine product use with ongoing regulations, it is crucial to bear in mind that changes in behaviour – such as smoking cessation or decreasing the number of cigarettes smoked – do not happen overnight. Neither do new regulatory initiatives; the process of deciding on a law, actually implementing it, and seeing the effect may take years (Bertollini et al.; Levy et al., 2004). Hence, for now it is not possible to draw any conclusions on the effectiveness of these new regulations on nicotine products in the Nordic and Baltic countries. Presenting how the Nordic and Baltic countries are working with this highly important public health challenge can – and hopefully will – be used in the work with future nicotine product preventive initiatives. 

Across the Nordic and Baltic countries, cigarette smoking continues to decline among youth, except for Latvia and Norway. The use of e-cigarettes is increasing among all countries, except for Lithuania and the use of oral nicotine products has increased across most Nordic and Baltic countries from 2018 to 2024. Most countries experienced a rapid increase in the use of e-cigarettes among youth from 2021 and the following years. Previously, the overall use of e-cigarettes in youth was relatively low, except in Iceland and Lithuania, where it was more prevalent already before 2021. Iceland saw a rapid increase already from 2015, which has been attributed to the lack of regulations (Kristjansson et al., 2019; Raitasalo et al., 2022).

The rapid rise in e-cigarette use among youth is probably associated with the launch of disposable e-cigarettes, also known as vapes, in many countries around 2021. A study from Denmark shows, for example, that most of the increase in e-cigarette use can be explained by an increasing use of disposables (Jarlstrup et al., 2023). Also in Latvia, the rapid increase has been attributed to the introduction of disposables, according to information provided by the Latvian national representative.

In Norway, the regulation of e-cigarettes differs from the regulation of other countries in this report, as nicotine-containing e-cigarettes are currently prohibited. Studies from before 2020 show that more than half of the youth currently using e-cigarettes are using e-cigarettes without nicotine (Tokle et al., 2022). In the last few years, however, Norway has also seen a rapid increase in the use of e-cigarettes among youth. Whether the tendency of use of e-cigarettes without nicotine continues has not yet been examined. In Finland, the use of e-cigarettes among youth initially declined until 2021, following strict regulations implemented in 2016. However, the introduction of disposables, which circumvent these regulations and are predominantly illicit, has contributed to more than a doubling of use of e-cigarettes among Finnish youth, according to information provided by the Finnish national representative. The issue of illegal disposable e-cigarettes as an explanation for the increasing use concerns most likely others of the included countries.

Some areas call for attention in examining the use of oral nicotine products and the following regulations across countries. Until the launch of oral nicotine pouches, the use mostly referred to snus, which has been on the market in Sweden for decades. With the development of new oral nicotine products, the terminology is still developing, both among researchers, politicians, and public health workers, but also among youth who are using these products. The knowledge on nicotine pouches is still evolving, and given that the pouches look very much like snus, the two products are easily confused (Vibjerg, 2023). Information on use across countries therefore varies; some countries measure the use of snus, others measure the use of nicotine pouches, and yet others measure the combined use of these products (table 1).

Overall, there is an increasing use of oral nicotine products in the Nordic and Baltic countries, which is most likely due to the launch of nicotine pouches. In Denmark, for example, until the introduction of nicotine pouches, oral nicotine products (snus) were not that prevalent among youth. Over the past few years, oral nicotine products have become quite popular – especially among boys, with almost one in five using them. Research shows that most of the increase stems from the use of nicotine pouches (Pedersen et al., 2022a). In Iceland, there was a rapid increase in the use of oral nicotine products between 2020 and 2021, which may be explained by changes in the measurements; since 2021, nicotine pouches have been included in the data. Additionally, the lack of taxation on nicotine pouches might explain the considerable rise in use in Iceland.

Among the countries in this report, Finland is the only one that has not seen an increase in the use of oral nicotine products. This may be explained by the fact that the indicator from Finland only included snus. Nicotine pouches were first measured in 2023, but only separately from snus and not combined for the 14–20-year-olds. Since April 2023, nicotine pouches have no longer been covered by the Medicines Act in Finland. An increase in both the sale and import of nicotine pouches has been seen (Lindholm, 2023). This may imply a potential rise in the use from 2023 onwards which has not yet been addressed (Ruokolainen et al., 2024).

Another key finding is the development of nicotine product use according to gender. While new nicotine products increase in popularity among both boys and girls, there seems to be a special increased popularity among girls. Oral nicotine products, i.e. nicotine pouches, are still most prevalent among boys, but the increase in use since 2018 has been more pronounced among girls. Hence, the gap between genders seems to narrow. This is also true for e-cigarettes, where the increase in use has been by far most pronounced among girls. As a result, across countries there seems to be a tendency of e-cigarettes becoming more common among girls than boys. 

Some of the contributing factors for this increasing use among girls may be related to attractive marketing features, such as a wide variety of flavours and designs of e-cigarettes. This may appeal more to girls (Piñeiro et al., 2016; Yao et al., 2016). Additionally, the absence of tobacco in some of the new products, i.e. in nicotine pouches, may create a perception of reduced harm, making them potentially appealing to youth who are typically more risk-averse (Czaplicki et al., 2022; O’Connor et al., 2022). Consequently, the growing availability of these products is reshaping the consumer landscape, drawing in new groups such as young girls who are traditionally less likely to engage in tobacco and nicotine use (Zetterqvist, 2024).

After decades of tobacco control, including the enactment of the European Tobacco Products Directive and the WHO Framework Convention on Tobacco Control, there are now quite uniform regulations overall for tobacco, i.e. cigarettes, across the Nordic and Baltic countries.

Although e-cigarettes are currently more regulated than newer products such as nicotine pouches, none of these common regulations incorporate e-cigarettes and nicotine pouches to the same extent as cigarettes. For the newer nicotine products, regulations are still developing. Therefore, at present, national regulations on new nicotine products vary markedly across countries. This is probably also due to differences in culture, political landscape, and development in the use of the products, as well as international regulations and initiatives, such as those issued by the EU and WHO.

Some of the regulations that vary between countries pertain to taxation, flavouring bans, and plain packaging on the newer products. For example, flavours other than tobacco are banned in e-liquids in Norway, Latvia, Lithuania, and Finland. Menthol flavouring is permitted in Denmark and Estonia, whereas there are no regulations in Iceland and Sweden of characteristic flavours in e-liquids for e-cigarettes.

Another example is the variety in the sales ban of nicotine products. Nicotine pouches are banned in Norway and Lithuania, snus is banned in all countries except Norway and Sweden, and e-cigarettes containing nicotine are to date banned in Norway. Further, there is diverse taxation of nicotine pouches from €0.02 per gram in Sweden to €0.22 per gram in Estonia.

New and pioneering initiatives have been breaking the uniformity. These initiatives include a change in 2021 from a ban on new nicotine products in Norway to an approval scheme. Nicotine-containing e-cigarettes and nicotine pouches have not been approved and are for now banned on the market in Norway (Helse- og omsorgsdepartementet, 2023). However, with the implementation of the TPD from 2014, which is expected to enter into force in Norway in 2025, e-cigarettes with nicotine will be allowed.

A promising initiative is seen in Latvia, where the Government decided that from 2025 the legal age of buying and using cigarettes, e-cigarettes, and nicotine pouches will be 20 years instead of 18. The long-term consequences may be wide-ranging; evidence shows that increasing the legal access age can prevent or delay the initiation of tobacco consumption among adolescents and youth (Institute of Medicine, 2015). Also, some countries are starting to regulate the amount of nicotine allowed in nicotine pouches. In Latvia, a nicotine limit of 4 mg enters into force on 1 January 2025. In other countries, such as Denmark and Finland, nicotine concentration restrictions have been proposed, but have not yet entered into force. (Sosiaali- ja terveysministeriö, 2024; Sundheds- og indenrigsministeriet, 2023).

Since 2018, all Nordic and Baltic countries have, to varying degrees, amended existing acts or drafted new ones to include or strengthen the regulations on e-cigarettes and oral nicotine products, particularly nicotine pouches (Figures 4.1–4.8). Additional amendments and regulations are planned, drafted, or still under discussion. For example, in Finland, several regulations on nicotine pouches, such as a flavouring ban, proper health warnings, nicotine content restrictions, plain packaging, and use restrictions have been suggested in a Government Proposal, and in Denmark, as a part of a new prevention plan, proposals of plain packaging, nicotine content restrictions, and a flavouring ban regarding nicotine pouches are in the pipeline (Indenrigs- og sundhedsministeriet, 2024c).

These regulatory variations have broader implications, particularly in the context of cross-border sales and enforcement. Some countries permit import of products from neighbouring countries, although the specific product cannot be sold within the country. This results in a legal sale of nicotine products across borders, affecting the actual availability of the products. For example, some Nordic countries permit the import of nicotine products for ‘personal use’. It is permitted to bring 1 kg of snus into Finland (Sosiaali- ja terveysministeriö, 2016), while the import of snus is completely prohibited in Iceland (Skatturinn, 2024).

Furthermore, trade of more than the allowed amount of banned products across borders, leading to illegal cross-border sales, affects the enforcement of a country’s national regulations (Salokannel & Ollila, 2021). The rapid increase of most often illegal disposable e-cigarettes challenges the regulation in many countries, for example in Denmark, where the use of flavoured disposable e-cigarettes is prevalent among youth although e-liquids with characteristic flavours are banned (Lund et al., 2024). In Norway, the availability of nicotine-containing e-cigarettes contradicts the current ban (Tokle & Bakken, 2023; Tokle et al., 2022), and much indicates that there is a market for illegal trade of nicotine pouches in Lithuania, despite the national sales ban (Onusaitytė, 2024). These challenges also reflect broader issues in the regulation and market dynamics. For example, the availability of illegal products on digital platforms may contribute to ease the product availability – also cross-border (Tokle & Bakken, 2023). To improve the adoption and enhancement of national regulations, more strategic cross-border collaboration is needed (Linnansaari et al., 2023).

To inspire future tobacco and nicotine preventive efforts in the Nordic and Baltic countries, it is relevant that these countries learn from the trends highlighted by the data in the report and act on them both in practice and politically.

The data shows that interest in new nicotine products is increasing among young people, and the trend indicates heightened popularity among girls. There may be many reasons for this, but in terms of preventive efforts, it is important to investigate in further studies whether it is girls in general, or if there are factors indicating that certain groups of girls use nicotine products to a greater extent than others. Such knowledge will be important for the precision of interventions. Girls’ nicotine addiction can also have other consequences, for example, on a foetus during pregnancy.

In addition to preventing the use of new nicotine products, it is also important that the Nordic and Baltic countries have relevant health-promoting measures available such as nicotine cessation services for young people who wish to quit their nicotine use.

Furthermore, to enable better direct comparisons of data across the Nordic and Baltic countries, there is a need for validated data that utilises the same age groups and measures in data collection. The lack of directly comparable data highlights a significant potential for increased Nordic and Baltic collaboration in this field, which could also strengthen cooperation within the framework of the Nordic Co-operation Programme for Health and Social Affairs 2025–2030.

The current and future regulations and amendments presented in the report also underline the importance of a continued strategic political focus not only within but also between countries. Collaboration and harmonising regulations across the Nordic and Baltic countries could help secure a more unified and proactive approach in preventing the increasing use of new nicotine products among youth and it would be a stepping stone toward maximising the Nordic Added Value in this regard.