Politique Internationale — What prompted you to study nicotine addiction early on in your career?
Karl Fagerström — I was working with drug addicts, and most of them smoked. They told me they wanted to quit smoking, but that it was very difficult—almost as difficult as quitting illegal drugs. I couldn’t believe it because, at the time, smoking was considered a bad habit, but certainly not a nicotine addiction. So I began to investigate the issue further and set up a smoking cessation clinic. That’s how it all began.
P. I. — How did you develop the famous “Fagerström Test”, and what exactly does it measure?
K. F. — I gradually realised that smoking isn’t just a behaviour, a habit you pick up. There’s something else. I suspected that nicotine was the substance at play. And I realised that, to understand my patients better and treat them more effectively, I needed to know to what extent their addiction was linked to nicotine. Just as with patients who have high blood pressure, it’s necessary to measure the severity of the condition. In my case, I wanted to analyse the degree of nicotine dependence: was it strong, weak, or even absent in some patients?
So I asked myself what characterises a person addicted to nicotine. This led to the creation of the “Fagerström Test,” which consists of six questions designed to assess smoking behaviour: the time before the first cigarette, the difficulty of not smoking in places where it is prohibited, the most important cigarette of the day, the number of cigarettes per day, the intensity of smoking in the morning, and smoking even when sick. Responses are scored from 0 to 10 to estimate the level of dependence, ranging from very low to very high.
P. I. — How reliable is the Fagerström Test, and how should clinicians use it in practice?
K. F. — The test has been validated against numerous variables, such as increased nicotinic receptors in the brain, withdrawal symptoms after quitting, and the success rate of quitting based on the level of dependence. Of course, many factors influence the ability to quit smoking, but the degree of nicotine dependence is one of the main ones.
I’ve even gone so far as to say that if someone scores the maximum—that is, 10—it’s nearly impossible for them to quit smoking. In that case, other strategies to reduce risks should be considered, such as switching from combustible products like cigarettes to “cleaner” delivery methods.
The clinician can use this test to understand the patient in front of them better and tailor the treatment. In cases of proven dependence, certain medications can help; there are several available today—Cytisine, Varenicline, Bupropion, etc.—as well as nicotine replacement therapies.
P. I. — Are you saying that for some people it is impossible to quit smoking, despite their efforts?
K. F. — It’s not entirely impossible, but almost. People who are highly dependent should not quit abruptly, they should reduce their
consumption gradually. This requires frequent follow-up, social support, and medication. Nicotine replacement therapies must be used at higher-than-average doses, and often for an extended period—sometimes for life—to prevent relapses.
P. I. — Some countries aim to achieve a tobacco-free generation. Is that realistic?
K. F. — We are making a big mistake in thinking it’s possible to achieve a drug-free generation. We aren’t even capable of preventing our teenagers from using illegal drugs like cocaine, cannabis, or amphetamines. So how could we possibly prevent them from using a relatively harmless substance like nicotine? And what about alcohol?
Most cultures, if not all, consume so-called “cultural” substances, such as alcohol, nicotine, and caffeine. Today, cannabis is gradually being added to this list. For example, in Germany, cannabis has been made legal, while certain nicotine products—even mild ones like nicotine patches—remain banned. This inconsistency raises real questions.
I often say, “When paradise exists on Earth, then yes, we can do without drugs.” But as long as life involves difficulties— and some people experience more than others—the desire to use substances to alleviate this suffering will remain. When faced with physical pain, we take a painkiller. In the same way, when faced with mental pain, anxiety, depression, or other hardships, we turn to whatever brings us relief.
There will therefore always be a need, not only for nicotine, but also for other substances. That is why it seems unrealistic to me to hope for a completely drug-free generation. Alcohol remains by far the most dangerous of all, due to its psychotoxic effects and the impaired judgment it causes, whereas caffeine and nicotine do not have the same impact.
If we accepted the very notion of addiction, as it exists for coffee, we could significantly reduce the harms associated with smoking by offering smokers much less harmful delivery methods, such as e-cigarettes or nicotine pouches. Thus, the risk of cancer, cardiovascular disease, or respiratory conditions would be greatly reduced. Addiction would certainly persist, but it would be far less dangerous, exactly as is the case with coffee.
P. I. — What alternative options can we offer?
K. F. — I don’t think we can truly achieve a tobacco-free generation by banning everything and simply saying: “You must not smoke cigarettes. You must not consume anything at all.” That doesn’t work.
Nicotine should be regulated just as alcohol is: based on the level of risk associated with different forms of use, discouraging intake of more harmful products and encouraging those that are less harmful. In the Nordic countries, alcohol is regulated in terms of taxation, availability, and age limits, depending on the level of risk associated with different forms of consumption. Beer, for example, which is the least harmful, is easily accessible, while spirits are much more strictly regulated. The same should apply to tobacco. It is interesting to note that the Food and Drug Administration (FDA), which regulates not only drugs but also tobacco products in the United States, has granted Swedish snus the status of the first modified-risk tobacco product, meaning it is less harmful. Snus is a smokeless tobacco product that is placed under the upper lip, where it gradually releases nicotine without producing smoke or vapor. It originated in Sweden and has a long cultural history in Scandinavia, where it is still widely used today.
P. I. — What biological mechanisms play a key role in nicotine addiction?
K. F. — What happens in the brain is very complicated, but we know it contains receptors that enable signal transmission. One of the most important is the acetylcholine receptor, on which nicotine acts as if it were acetylcholine: specifically, when a person smokes, nicotine reaches the brain very quickly (within seconds) and binds to these specific receptors, which are therefore called nicotinic receptors. This mechanism triggers the release of dopamine, a neurotransmitter associated with pleasure and reward.
The brain then associates the cigarette with a reward, which generates the urge to start smoking again. When one smokes regularly, the number of nicotinic receptors increases, and thus more and more nicotine is needed to achieve the same pleasurable effect. Thus, the increase in the number of nicotinic receptors is the primary mechanism that creates nicotine dependence. If one stops smoking, there are then too many receptors available, which causes withdrawal symptoms with strong cravings for nicotine: “I need my nicotine!” the brain cries out, which is very difficult to overcome.
P. I. — What is the profile of the most addicted smokers?
K. F. — The two most important questions in my test to measure nicotine addiction are, on the one hand, the time before the first cigarette or nicotine use in the morning, and on the other hand, the number of cigarettes smoked. The time of the first morning cigarette is important because nicotine is rapidly metabolized in the body. In the morning, there is no nicotine left in the body. A dependent person is therefore already experiencing withdrawal upon waking. If they can wait several hours before smoking, their dependence is low. But if they smoke within 30 minutes, their dependence is stronger. The other important sign of dependence is the number of cigarettes smoked.
Today, we also see that smoking is increasingly concentrated among the most disadvantaged socioeconomic classes. There are several reasons for this: they may be less informed than more educated groups, but they also face more difficult living conditions than the better-off. These individuals sometimes seek a means of escape—drinking alcohol, using nicotine, or even other drugs—to find some respite from a life that may be difficult or unsatisfying.
P. I. — What role should nicotine replacement therapies or e-cigarettes play?
K. F. — A particular aspect of nicotine is that, to feel the effect quickly, the product must reach the brain rapidly. Cigarettes allow for this, whereas a nicotine patch takes nearly an hour to take effect. The problem is that, because of it’s low-dose, the patch doesn’t cause addiction, but it also doesn’t provide pleasure, and therefore doesn’t help people quit smoking.
Beyond nicotine, smoking a cigarette creates habits, behaviours, and gestures that themselves become a full-fledged addiction: this is what’s called behavioural addiction. This effect is not replicated by simply chewing nicotine gum, using snus, or applying a patch. This is why cigarettes are the most addictive form of tobacco. E-cigarettes also create behavioural addiction because their gestures closely resemble those of smoking a cigarette. This is also the case with heated tobacco. All these nicotine products are addictive, but addiction and nicotine are necessary to make the switch from one product (the more harmful one, namely cigarettes) to another (the less harmful ones, namely heated tobacco, e-cigarettes, or nicotine pouches).
Therefore, to help someone quit smoking cigarettes, if standard treatments (nicotine replacement products sold in pharmacies, medication, hypnosis) do not work, e-cigarettes or heated tobacco should be tried.
P. I. — Which public policies are most effective?
K. F. — Generally, it is believed that higher taxes on tobacco products are the most powerful factor in reducing smoking, and that smoking bans also contribute somewhat to this decline, even if the decrease is not very rapid or pronounced. That is why it is important to have alternative options. For example, in Sweden, only 5% of people smoke, but about 15% use snus. This creates an alternative: if you can’t smoke cigarettes because they’re expensive or banned in certain places, you can use another product, which also helps people quit smoking.
In my country, where snus use has a long history, the government isn’t aiming for zero smoking, but to minimize health risks. Addiction isn’t the main challenge; the real problem is lung cancer. The goal should therefore be to reduce harm rather than eliminate all forms of addiction.
P. I. — While France has sharply increased the price of a pack of cigarettes, the French remain among the heaviest smokers in Europe. Is this proof that taxation is ineffective?
K. F. — Of course, cigarettes should never be cheap, but raising the price poses a moral and social problem. Today, smoking primarily affects the lowest socioeconomic classes. The goal is to change a situation of addiction, which is a very difficult task. Most people continue to buy cigarettes, even if the price per pack goes up. As a result, this reduces their purchasing power: they have fewer resources to fund their children’s education, their food, or other essential needs. I therefore believe it is necessary to set a price cap on cigarette packs, so as not to exceed certain limits. If cigarettes weren’t addictive, people would respond more readily to price hikes and change their behaviour. But, specifically speaking we are not dealing with ordinary products: in the case of addiction, the price effect is not as dissuasive. And we cannot leave people without a solution.
P. I. — What are the main challenges legislators must address to avoid encouraging the black market or unregulated use?
K. F. — We always come back to this question: is it realistic to aim for a drug-free generation? I have met many smokers throughout my career, so I know how essential and indispensable nicotine is for some users. That is why I believe we must accept a certain degree of addiction, just as we accept it for caffeine. I would even go so far as to say that nicotine isn’t a lot more harmful than caffeine. The difference isn’t huge. Alcohol, on the other hand, is much more harmful.
If different countries made tobacco more expensive and harder to obtain, while offering cheaper and safer alternatives, then we could eliminate cigarettes. The World Health Organization has set a target of limiting smokers to 5% of the population. We could be much more ambitious and set a goal of zero smokers, provided we allow the use of nicotine in safer forms. That would be the best scenario for public health.
P. I. — What advice would you give to France?
K. F. — We should encourage nicotine pouches, which are less harmful and increasingly popular, provided we pay close attention to their composition and set a maximum nicotine limit. Some brands have no qualms about selling pouches containing 15 to 20 mg of nicotine, or even more, which is far too high. There is no need for more than 10 mg of nicotine per pouch. These products deserve to be taxed less than cigarettes because they are less harmful.
The same applies to e-cigarettes, which should also be subject to different taxation: they are probably slightly more harmful than nicotine pouches, but certainly less so than cigarette smoke. The same reasoning applies to heated tobacco. France should also look at what the FDA is doing in the United States: the U.S. agency has assessed the risks and benefits of heated tobacco and found it to be less harmful than cigarettes.
It is clear that the same scientific data is not being used in the same way.
It is interesting to note that in the European Union (with the exception of Sweden), snus is banned, whereas in the United States it is promoted as a less harmful product. Similarly, nicotine pouches are banned in France, whereas in the United States they are encouraged as a substitute for cigarettes.
P. I. — What specific measures do you recommend for young people?
K. F. — Marketing should not target young people. Packaging must be designed so as not to attract them. Similarly, product flavours must be restricted so as not to appeal to teenagers. Packages must also be large enough to be expensive and difficult for young people to purchase. These are a few measures that, I believe, society can implement. But, I repeat, we must not believe that we can achieve zero use of these cultural drugs: alcohol, nicotine, caffeine, or even cannabis.
P. I. — Which countries are currently the most effective?
K. F. — A lot to be learned from the United Kingdom, which has established smoking cessation clinics throughout the country. The British government has also offered free e-cigarette starter kits to smokers who wanted to try using them to quit smoking. In other countries, there is a push to ban them completely. Sweden, which seeks to reduce harm without necessarily reducing use, has also made good choices and boasts the lowest smoking rate of any country.
