Karl Fagerström: ‘A tobacco-free society is a realistic goal, but a nicotine-free society is difficult’

The clinical psychologist and creator of the Fagerström test talks about therapeutic options for people with tobacco use disorder

Karl Fagerstrom
Karl Fagerstrom at the V National Congress for the Prevention and Treatment of Smoking.J.M.GARCIA (EFE)

Forty-five years ago, when he had just turned 30 and was working in a unit that looked after people who wanted to quit smoking, clinical psychologist Karl Olov Fagerström devised the so-called Fagerström test — a brief questionnaire, made up of eight questions, to assess a smoker’s addiction to nicotine. Four decades on, the test is still used, just with two fewer questions.

“The test offers a rough estimate of a given smoker’s likelihood of successfully quitting,” explains Fagerström, who initially designed the test for individual use, since it allowed him to diagnose his patients and personalize treatment based on the level of their disorder.

At 76 years of age, having become one of the most authoritative voices in the world on smoking and a headliner at each congress in which he participates, Karl Fagerström continues to travel around the world sharing his knowledge and experiences. A founding member of the Society for Research on Nicotine & Tobacco (SRNT), Fagerström was in Seville, Spain at the beginning of June, where he participated in the 25th Congress of Dual Disorders — an event that brought together more than 1,500 experts in mental health and addictions in the Spanish city. While at the congress, he spoke to EL PAÍS about the therapeutic options for people with tobacco use disorder who want to quit or reduce the harm caused by smoking.

Question. Although nicotine has been demonized across the world, you argue that, in the long term, it does not present any more risk than other substances of habitual consumption.

Answer. Yes, pure nicotine has an impact on an individual’s health equal to that of caffeine and is less harmful than alcohol.

Q. So, should nicotine be separated from tobacco in its clinical consideration?

A. Yes, since pure nicotine is significantly less harmful than putting tobacco on fire and inhaling all the combustion products, there are strong reasons to move away from combustion. Coffee would also be very harmful if it underwent a combustion process. The health risk of tobacco come mainly from the about 70 non-nicotinic carcinogenic substances and the substances such as carbon monoxide, which cause cardiovascular disease. The respiratory effects of tobacco, such as COPD, would also largely be avoided if the combustion process could be avoided.

Q. Nicotine, in any case, does not cause addiction. In Spain, according to a 2022 survey, 34% of women and 44% of men have used tobacco in the last 12 months. Given these figures, is it possible to consider a tobacco-free society?

A. Yes, I think a tobacco-free society is a realistic goal, but we will hardly achieve a nicotine free society. In medicine, there is also the principle that where you can not cure, harm should be reduced. Where people who want to quit cannot, they should be offered less harmful alternatives. Those who do not want to quit smoking should be discouraged to smoke and helped to switched to less harmful alternatives. We are talking about products that administer nicotine, with or without tobacco, but whose use does not imply combustion, which is what is really harmful.

Q. Does harm reduction explain the data from Sweden, where according to the Eurobarometer the prevalence of smoking was 4% in 2021?

A. The usual anti-smoking measures have been introduced in most countries and some are better than in Sweden, so it is very likely that the snus [tobacco marketed in bags for oral consumption] has played a big role. The most common smoking cessation product used by Swedish men is snus. In fact, using snus as a cessation aid has also been found to be more efficacious than other aids, including nicotine replacement therapy (patches, gum, etc.) and drugs such as Champix [the brand name for varenicline]. This has resulted, according to data from the World Health Organization, in Swedish men having the world’s lowest rate of deaths and illnesses attributable to smoking. And this is revealing data, because Swedish men consume as much tobacco as men from any country in the European Union, but as you said before, very few, barely 5%, smoke.

Q. Can e-cigarettes also be considered a harm reduction policy?

A. Yes, as long as the use among adults is a greater gain for public health than the primary uptake among youths. In the end, with electronic cigarettes we assume a risk: that young non-smokers of tobacco, attracted by its flavors, start using them. To harvest the potential of e-cigarettes as a harm reduction tool, a sensible regulatory system need to be in place. Nicotine containing products could for example could be regulated as alcohol is regulated in the Scandinavian countries.

Q. The UK nation health system (NHS) recently announced that one million smokers will receive a free vaping starter kit to encourage them to quit tobacco products.

A. think it is a great way of stimulating smokers to test e-cigarettes that would down the road help smokers to quit and possibly also help e-cigarette users to quit with all nicotine. It has also been found that the dependence to e-cigarettes is lower than that to regular cigarettes.

Q. The Spanish Society of Medical Oncology (SEOM), however, warned on May 31, on World No-Tobacco Day, that new forms of tobacco use, including vaping and electronic cigarettes are just as harmful as tobacco.

A. I don’t think so. Of course, we do not yet have long-term epidemiological studies to show that e-cigarettes are less harmful, but we do know that they contain less toxic substances than regular cigarettes and also that users’ exposure to these toxic substances is much lower. For this reason, among other things, the U.S. Food and Drug Administration (FDA) also gave them marketing approval [the first three electronic nicotine delivery systems were approved in October 2021]. Does this mean that electronic cigarettes are a healthy product? Definitely not. Their long-term use can cause addiction and could also be harmful to health. For me, the biggest problem with e-cigarette ingredients is the flavorings, many of which are not approved for inhalation. I think if one could use safe flavors, there would be evident harm reduction. Traditional cigarettes are killing people around the world every second. That’s unlikely to happen with e-cigarettes.

Q. The vast majority of people with a mental disorder also have tobacco use disorder, known as dual pathology. According to data from the United States and the United Kingdom, almost half of the cigarettes sold are purchased by people with mental disorders.

A. Harm reduction in mentally ill is even more important because they smoke to a higher prevalence and also more cigarettes per day, inhale more deeply, and respond much worse to smoking cessation strategies. For this reason, among other things, this population group dies between 15 and 20 years earlier than the general population, with the consequences of smoking being the lead cause of these deaths. In the special case of schizophrenics, nicotine may even be therapeutic, which reinforces the idea of harm reduction.

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