A thickening plot: components and complexities in the political framing of the smoking problem in Sweden, 1957–1993

Abstract

Swedish state regulation of tobacco use came much later than the regulation of alcohol and drugs. Only in 1993 did the first more comprehensive regulatory act – the Swedish Tobacco Act – come into force. By examining the political prehistory of the act in 1957–1993, this article analyses the increasingly complex problem description that made the new legislation possible. The article shows that different parts of the problem description – harms to others, a connection to the public health discourse, and an increasing medicalisation – came to reinforce each other, but also that all essential components were in place from the outset and that research confirmed established descriptions rather than drove the development.

Keywords:

• Smoking
• Medicalisation
• History
• Sweden
• 20th Century

Introduction

The first comprehensive tobacco control law in Sweden was adopted in 1993 (SFS 1993:581). While it left plenty of room for future amendments, the 1993 Tobacco Act can be regarded as the first piece of Swedish legislation which sought overall to curb the use of tobacco products: the act laid down provisions regarding health warnings and restrictions on smoking in certain indoor and outdoor locations, as well as restrictions on the trade and marketing of tobacco products. In comparison with legislation on other problematic psychoactive substances, the Tobacco Act appears as a case of belated political institutionalisation. For example, alcohol consumption was targeted by ambitious legislative measures as early as the 1910s with the introduction of strict trading regulations and coercive care (Edman, 2005). The use of narcotics, which was scarcely acknowledged as a social problem in the early 1960s, was by the end of the decade already addressed by comprehensive legislation regulating the entire chain from production and smuggling to trade and treatment (Edman, 2016).

By examining the political prehistory of the act in 1957–1993, this article analyses the increasingly complex problem description that made the new legislation possible. The article shows that different parts of the problem description – harms to others, a connection to the public health discourse, and an increasing medicalisation – came to reinforce each other, but also that all essential components were in place from the outset and that research confirmed established descriptions rather than drove the development. How was the tobacco problem constructed during the studied years? What role did new research play in the political rhetoric? How did this change over time?

Material and method

A broad review of the Swedish parliamentary records from the early 1900s shows that there have been two formative periods with a decisive impact on how the tobacco question has been conceived. The first takes us from the late 1950s to the early 1970s, when the agenda was occupied by the harms of tobacco to the individual together with demands for restrictive measures. The second formative period were some of the early years of the 1990s, when smoking was discussed within an established framework of substance dependence but also became one of the most emphatic examples of a new kind of public health problem.

The source material consists of parliamentary proposals and government bills, parliamentary committee reports, and parliamentary debates and inquiries from 1957–1993. All source material is available at the Swedish Parliament Library and from the mid-1970s also as digitised documents via the Swedish Parliament’s website. Relevant material has been identified via the keyword register at the Parliament Library and search strings on the Swedish Parliament’s website. In the material, we have mainly searched for relevant components in commonly encountered problem descriptions regarding, what is considered as the problem of tobacco smoking, what the problem depends on and what to do about the problem. These descriptions have been excerpted, compiled and thematised for the periods 1957–1973 and 1990–1993 respectively, which have then been the basis for the analysis.

We will first outline the main features of the tobacco problem by reviewing historical and social scientific research in this area, and will then turn to the empirical study of the two formative periods. The article concludes with a summarising discussion.

The tobacco problem

To analyse state control, one needs to recognise and examine the dominant understandings of a problem. Here, our chosen premise is the way in which previous research has seen the tobacco problem as developing during the 20th century: from ‘harms to smokers’ to ‘harms to others’ and to constituting ‘addiction’ (Cisneros Örnberg & Sohlberg, 2012; Hakkarainen, 2013; Hellman, Hakkarainen, & Saebø, 2016). While the various problem descriptions and their internal relations make analytical sense, it has been necessary to contextualise the historical development to suit the Swedish circumstances.

More or less well-founded notions of harms to smokers have circulated ever since Christopher Columbus made his acquaintance with the tobacco plant towards the end of the 15th century, and the notions kept growing stronger from the 17th century on (Goodman, 1993; Nordlund, 2005). The poisonous properties of nicotine were discovered at the beginning of the 19th century, but it was only a hundred years later that the health effects of tobacco were beginning to be more widely discussed in the public debate (Nordlund, 2005). Tobacco was equated with other noxious substances – such as alcohol, opium and morphine – and anti-tobacco organisations emerged in several countries (e.g. Elliot, 2010; Feldman, 2001; Hooker & Chapman, 2007; Lindgren, 1993; Saebø, 2014). The link between smoking and lung cancer was already observed in the 1920s, and was corroborated and highlighted in several studies in the 1950s (Goodman, 1993; Hellman et al., 2016; Nordlund, 2005). According to previous research, it took joint research efforts in the United Kingdom and the United States in the 1960s to establish the cancer scare as an unavoidable political issue and to help make smoking regarded as a major public health problem. (Brandt, 1991; Goodman, 1993; Hakkarainen, 2013; Nordlund, 2005).

Harms to others, mostly as a result of passive smoking, were already noted in Sweden around the turn of the 19th and 20th centuries, but as in many other countries, it only became a politically viable notion at the end of the 20th century (Bailey, 2004; Lindgren, 1993). According to previous research, a number of 1980s research reports that established the connection between passive smoking and cancer finally brought the problem into the realm of environmental public health discourse (Berridge, 2007; 2013; Hakkarainen, 2013; Nordlund, 2005). But public health is by no means a clear-cut framework with obvious implications. The more pronounced breakthrough of public health action in the mid-19th century can be described as a medical, scientific, and social reform movement which sought to eliminate the pathogenic conditions found in poor housing, inadequate sanitary provisions, dangerous workplaces, and poverty in general (Fairchild et al., 2010). The early public health ideology was thus partly marked by its attention to societal structures and by its social activism and ambition to improve the living conditions of large sections of the population. Literature juxtaposes this with New Public Health, which has during the post-war period to an increasing extent shown a greater concern for chronic and lifestyle diseases (Porter, 2008). With an emphasis on risk factors, New Public Health embraces the perspective of a vaguely defined neoliberal society, where health is the responsibility of each individual (e.g. Gabriel & Goldberg, 2014). This perspective sees education and prevention as techniques above all else in the service of improved public health, and it has since the 1990s been underpinned and validated by its own research field – prevention science – which clearly shifts the responsibility onto the individual while brushing aside the more ideological questions (Roumeliotis, 2015). Much of the post-war New Public Health has focussed on smoking in particular, so much so that, for example, the 1950s coupling of smoking and lung cancer took its cue from New Public Health by stressing the individual’s responsibility rather than a smoking ban (Berridge, 1997; 2006; Brandt, 1991; Porter, 2008; Saebø, 2012).

The conception of tobacco use as an addiction lends the problem construction added complexity. The influential characterisation of addiction as a brain disease which for various reasons mainly emerged in the United States in the 1960s has paved the way for addiction as a universal concept potentially able to capture wildly differing phenomena (Vrecko, 2010). As if drawn by a centripetal force, different things are subsumed under an umbrella notion – that they are in effect the same (and that this would explain things). This problem description has been criticised for defining pathological behaviour on the basis of non-medical and subjective factors, and the diagnostic criteria have been labelled circular and descriptive rather than explicative. (Cantinotti, Ladouceur, & Jaques, 2009; Davies, 1997; Reith, 2004). The difficulties of attaining analytical precision can also be traced to a conceptual level: the disease model is really a metaphor, an analogy mistaken for a homology (Hellman, Schoenmakers, Nordstrom, & van Holst, 2013; Rantala & Sulkunen, 2012).

The notion of the tobacco vice as a hard-to-break habit and as a craving which defies all knowledge and rationality admittedly existed long before the late-20th-century labels of tobacco use as an addiction (Goodman, 1993; Saebø, 2014). And while the concept of addiction was not applied as such, we can recognise strains of this problem description in studies of phenomena termed as tobaccomania or tobaccoism (Goodman, 1993). The addictive properties of nicotine were already discussed in Sweden at the turn of the 19th and 20th centuries, and tobacco was compared with other addictive drugs. Regular smokers or ‘nicotinomaniacs’ were likened to alcoholics or morphinists. At this time there were also treatments which focussed on the dependence aspect in order to help smokers kick their habit (Lindgren, 1993). Berridge (2007) argues however that the popular view of smoking as serious dependence kept lacking the institutional or professional legitimacy that could have placed the question on the political agenda in Britain. It was not until the early 1940s that smoking began to emerge as an addiction in the British research, and it took another ten years for psychological dependence to be included in treatment schemes (Berridge, 1997; Elam, 2014). The first British rehabilitation clinic opened in 1962 (Berridge, 1998), while a similar institutionalised treatment model had already found a place in Swedish rehabilitation clinics in the mid-1950s (Elam, 2014).

The World Health Organisation has since the 1960s also used the concept of dependence in various reports and diagnostic manuals, which treated different habit-forming behaviours as a part of the same phenomenon (Taylor, Berridge, & Mold, 2016). This characteristic of tobacco as one of many addictive drugs has been widely identified since the 1960s and has also led to more pronounced government measures of control and regulation (Hooker & Chapman, 2007). Still, as the medicalisation process was hardly identical from one country to another, it makes little sense to try and sketch a universal chronology. Elam (2014) shows that the influential U.S. Surgeon General’s report on smoking (1964) describes smoking as a psychological craving – habituation – to keep it distinct from a full-blown discourse of addiction, which found its way to the report as late as 1988. During the 1990s, says Berridge (2007), addiction began to feature more prominently in the problematisation of smoking: both pharmaceutical interventions and genetics were given a more pivotal role in treatment.

Different historical developments in different countries in different discursive arenas makes it impossible to present a simple chronological timeline of the triad of harms to smokers, harms to others and addiction. It is nevertheless possible to identify a process of mutually enhancing characteristics even considering the specific, non-universal, developments. The attention to the health effects of smoking and accounts of pathological states of dependence have at least two things in common. First, the very connection to a disease allows a potential medicalisation, as the problem will be treated or at least noted by professional groups, bureaucratic institutions and political actors with responsibility for and/or interest in conditions labelled as a disease. The shift from a disease as a consequence of tobacco use to a disease as the very cause has been readily made in various circles focussing on health and disease, and a similar trajectory is evident in how alcohol and drug use have been conceived since the mid-1800s (Edman, 2018b; Edman & Olsson, 2014). Second, conceptions of a phenomenon as a disease feed each other. On the one hand, action against unhealthy behaviour gets more complicated if the causes of this behaviour can be explained as a pathological drive which can be seen as undermining an individual’s rational decision making. At the same time, this helps to feed a collective demand for the habit-forming product, making political decisions to curb consumption so much harder. On the other hand, dependence, which is hardly a problem as such, becomes key to the very conception where the habit-forming product also damages one’s health. As Berridge (2007, p. 242) has shown, this ‘policy fact’ also helps to make demands for medical treatment stronger. Added to this is the notion, growing more widespread with time, of smoking as a public health problem. The public health framing may be vague and in the political rhetoric it seldom does anything else than underline the severity, extent and/or harmfulness of the problem, but it nevertheless contributes to the overall conception of a serious health issue which affects a great many people and where political measures are met with particular obstacles because of the very question of dependence.

Results

Insofar as the relationship is concerned, the above-mentioned research expresses a rather unproblematised belief that clear research results have led to certain policies. However, as also has been shown above, there were wide-spread notions of all aspects of the tobacco problem (harms to smokers, harms to others, addictiveness) long before the research-based comprehension of the tobacco problem took shape, and as will be shown below, it was certainly possible to make policy of the tobacco problem without support in any unambiguous research.

Towards a medical understanding

At the beginning of the study period, in 1957, cigarette smoking in Sweden was widespread, but according to Torell (2002), it was discussed as a medical problem only very occasionally. For example, smoking was absent altogether from the 1950s Swedish medical manuals. The smoking problem was at times tackled in the political debate in the late 1950s, but the harmful effects of tobacco use gained more political prominence only in the 1960s. Previous research has seen this as a manifestation of the connection between smoking and lung cancer, which was being corroborated in several notable research reports (Cisneros Örnberg & Sohlberg, 2012; Nordlund, 2005; Torell, 2002). The Swedish parliamentary sources show that smoking was linked to a range of diseases, not just cancer, and that smoking was seen as leading to increased health care costs, lost working days and, at its worst, death (PBF, 1964:12; PBS, 1961:389, 1967:92, 1967:151, 1968:66, 1968:118, 1968:611; PRF, 1964:12; PRS, 1969:43; GB, 1963:77). But not all smoking was conceived as problematic. It was agreed on more than one occasion that misuse rather than use as such gave rise to the diseases (e.g. PBS, 1961:400; PRS, 1965:15).

Already before the influential British and American research reports made the connection between smoking and lung cancer, the Swedish responses to the smoking problem would refer to international research which advocated measures such as advertising bans, education campaigns, warning messages on cigarette packs, banning smoking in public places, and age limits – which were also being implemented in several countries as of the 1950s (Bailey, 2004; Bjartveit, 1998; Hakkarainen, 2013; Hooker & Chapman, 2007; Saebø, 2012). From the latter half of the 1950s, the Swedish parliamentary debates referred to research and inquiries as a knowledge base while also calling for more research and inquiries to be conducted (PBF, 1957:393, 1957:395, 1964:71; PBS, 1961:268, 1961:389, 1964:234; PRS, 1962:15, 1964:21, 1965:15, 1969:43; GB, 1963:77; SLC, 1964:9/2/23). The two most keenly debated proposals by Swedish politicians were various educational campaigns and a ban against tobacco advertisements.

An advertising ban was not uncontroversial (e.g. PRS, 1962:15, 1962:26) and would not be realised until 1993. Those in favour of the ban argued that tobacco advertisements were misleading and seductive, glorified their subject and were (hardly surprisingly) ‘conducive to increased consumption’ (PRF, 1964:12, p. 124. Also: PBF, 1964:71, 1964:647; PBS, 1967:151, 1968:611; PRF, 1959:16, 1964:12, 1967:39; PRS, 1958:10, 1959:18, 1964:12). One of the anti-advertisement successes included limited regulation effective as of 1970: one was not ‘to use expressions and phrases or images of circumstances or environments which can be assumed to appeal to teenagers in particular’ (PRS, 1969:43, sp. 102). For their part, the anti-regulators pointed out that the tobacco companies already addressed the issue responsibly, that banning advertising would probably be ineffectual, and that a ban would clash with the decree on the freedom of the press (PRF, 1964:12, 1967:39; PRS, 1962:26; 1964:12; SLC, 1964:9/2/23). Just like when gambling restrictions were debated in the 1970s (Edman & Berndt, 2016), the Social Democrats also voiced their critique of a general nature that government bans would override individual freedom of choice (PRS, 1964:12). And just like when a gambling ban was debated, one may assume that the government had its eye on the tax revenue that could be lost (PRS, 1958:10, 1962:26, 1967:39; GPC, 1958):11/B2.

As already mentioned, passive smoking had been recognised as a problem in Sweden around the turn of the 19th and 20th centuries, and according to Torell (2002), complaints about smoking indoors in public places began to be increasingly vocal during the 1970s. However, according to our study, it was already in the 1960s that indoors smoking made its way into the political debate. The link between passive smoking and ill health was already suggested in the late 1950s, but cautiously, suggesting that tobacco consumption could cause harm ‘both on the one who uses tobacco and sometimes even to a certain degree on the environment’ (PRS, 1959:18, sp. 41). The connection between tobacco smoke and cancer was sometimes held at arm’s length by referring to the fact that research findings in the United States and England had shown this (PBS, 1964:234), but that the politicians also had to act ‘[in]dependent on the relationship between smoking and lung cancer’ (PBS, 1961:389, p. 1). People’s health could be harmed by passive smoking (PBS, 1964:88; PRS, 1964:21) but it was primarily other consequences that were raised as arguments for a regulation: ‘pain in the eyes, fatigue and headache at stay in smoky premises’ (PBS, 1961:389, p. 5); that the non-smoker had difficulties in maintaining an intellectual and otherwise psychic efficiency during e.g. a meeting in an atmosphere full of tobacco (PBS, 1964:88, p. 11); that some people were ‘hypersensitive or allergic to tobacco smoke’ or that tobacco smoke caused the non-smoker ‘sour eyes’ (PRS, 1964:21, p. 80). To a large extent, tobacco smoke was regarded as a nuisance and irritation rather than a disease cause and the solutions aimed at managing and possibly controlling smoking in premises where smokers and non-smokers had to be at the same time, something that made policies mainly applicable at workplaces:

In workplaces, including office spaces, meeting rooms, and so on, where smokers and non-smokers are staying together, tobacco smoking should not, in our opinion, be allowed, and if it is all parties should first agree upon it. However, since we find it hard to see that such an agreement can be established in most cases, we consider it most appropriate that smoking in designated premises is no longer permitted and that smokers are referred to smoking breaks in special spaces in connection with the above premises (PBS, 1964:88, p. 11 f).

The question, therefore, became more of an occupational health concern than a medical question, and references were also made to the occupational health legislation’s formulation that the employer was obliged to ‘provide “healthy designed” premises’ (PRS, 1964:21, p. 79. Also: PBS, 1964:88). This framing was however not self-evident in the mid-1960s and a right-wing MP could argue that ‘significantly more members of parliament would be present in the chamber during the debates if we were allowed to smoke there’ (PRS, 1964:21, p. 82).

The passive smoking argument was aided by the conception – not yet overly common – that smoking constituted a public health problem, meaning either that many were afflicted, that the problem was growing or that the health effects were considerable (PBF, 1957:395, 1964:71, 1964:647; PRF, 1963:22; PRS, 1957:10, 1962:15; GB, 1963:77). The issue lacked obvious impetus and had to contend with an unwillingness to ‘infringe on the rights of others [that is, the smokers]’ (PRS, 1964:21, p. 80). By the beginning of the 1970s, there were, however, more frequent calls to make canteens, public transport and public places smoke-free (PB, 1970:117, 1973:26, 1973:46).

Smoking was being increasingly perceived as a dependence problem already towards the end of the 1950s, that is, at the beginning of the study period. Articles in the Swedish medical press conceived of smoking as a disease and advocated anti-smoking measures, often with chemical preparations (Nordlund, 2005; Torell, 2002). Descriptions of smoking as misuse can also be found in the parliamentary debates ever since the very beginning of the study period (PBF, 1964:115; PBS, 1957:497, 1961:268, 1961:400; PRF, 1964:5; PRS, 1957:10, 1959:18, 1962:13, 1965:15; GB, 1963:77; SCS, 1963:6/1/97), but not in pathological terms to begin with. In the mid-1960s, tobacco was described as a ‘bane of civilisation’ (PRS, 1964:12, p. 166) together with alcohol, leading to speculations about ‘the physiological forces behind the smoking habit’ (PBS, 1964:234, p. 6. Also: SLC, 1968: H9/2/48). That smoking was addictive was, however, a well-established collective experience which did not need research results to validate what was already known. In the 1960s, people were said to be ‘lured into a tobacco dependency’, and inveterate smokers were described as ‘well and truly trapped’ (PRS, 1967:39, p. 59). A couple of years later smoking was ‘a habit that was hard to break’ partly because ‘the very use of tobacco gradually adds to a physiological and psychological need’ for the substance (PB, 1971:878, p. 12).

Most of all, however, it was the response and its institutionalisation that implied that one was dealing with a pathological state. In the words of the 1963 governmental bill on anti-smoking measures, the solution was sought in ‘medically, socially and psychologically effective action’, in part to discourage ‘tobacco misuse’ (GB, 1963:77, p. 31). A similar problem description, growing more established, was also referred to in the parliamentary debates about sales and marketing restrictions on tobacco products, based on restrictions already introduced for alcohol products (PBF, 1957:395; PRF, 1964:12; PRS, 1958:10, 1964:12), and the proposed educational campaigns included measures already taken against alcohol consumption (PRS, 1962:13). But more than anything else, the smoking rehabilitation clinics which opened in the mid-1950s showed concretely that smoking was increasingly understood as a pathological dependence. The proposals to finance these clinics from tax revenue can be said to amount to an official authorisation of this very problem description (PBS, 1961:389, 1968:118; PRS, 1961:23, 1967:39). The clinics offered medical and therapeutic treatment, and while the results were mixed, both the National Board of Health and many MPs felt positive about further developing their work (Elam, 2014; PBF, 1964:115; PBS, 1961:389, 1968:118; PRF, 1961:23; PRS, 1961:23, 1965:15, 1967:39). The political seal of approval made it clear that one was dealing with dependency, even if the clinics had such goals as help smokers to ‘get rid of the complex habit’ (PBS, 1961:389, p. 1; PBF, 1964:115; PRF, 1961:23; PRS, 1961:23; 1964:15). The concept of treatment was also beneficial in another respect: the Social Democratic government was able to brush aside any ideas to ban sales of tobacco, which was the goose that laid the golden egg. They pointed out that this was mainly ‘an issue of education, possibly also of rehabilitation, which is where the question of detoxification clinics can be relevant’ (PR, 1971:12, p. 6). This medicalisation of the treatment level grew increasingly powerful with the introduction of nicotine chewing gum in the 1970s (Berridge, 2007; Elam, 2014).

The medically-oriented response was similarly reinforced by the debates about the inclusion of smoking in the health insurance system. From the 1930s onwards, the health insurance system had been debated in the question of alcohol misuse, which helped to lay an institutional base for a medicalised understanding of the issue. The debate re-emerged as a part of the medicalisation of alcohol misuse in the mid-20th century and was eventually tackled by the 1961 inquiry into the health insurance system. In their report in 1969, the committee concluded that those treated in public alcoholic institutions should be regarded as sick and entitled to sick pay (effective as of 1974) (Edman, 2004). The 1961 inquiry also spurred the parliament to debate the disease status of smoking by discussing whether or not it could be applied to smoking rehab treatments. Might the inquiry also deal with the use of tobacco? Detox treatments did seem to prevent future health issues but the key question was whether they could be said to treat already existing diseases, that is, whether smoking could be considered a disease in itself in a similar manner as alcohol misuse had come to be identified as the disease of alcoholism. This mattered because legislation on public health insurance stipulated that medical care costs be compensated in case of a disease but not in order to prevent a disease. What harmed the case of tobacco in the mid-1960s was that ‘[t]obacco misuse […] in medical terminology [was considered] a “bad habit” rather than a disease’ (PRS, 1965:15, p. 147). Attempts to change this condition were made by a liberal MP, who maintained that smoking, in fact, created a dependency in a like manner with alcoholism. The need for treatment was likened to an indication of the disease itself, and the fact that the public health insurance system did not cover this was lamentable, especially considering that ‘tobacco misuse was frequently regarded as a disease by the medical profession’ (PBF, 1964:115, p. 7). The parliamentary inquiry into the public health insurance system did nevertheless not report on the inclusion in the system of smoking detoxification or designated clinics.

Following Conrad and Schneider (1980; Conrad 1992), one can claim that the medicalisation of smoking was accomplished on the treatment level in the mid-1970s thanks to the tax-funded rehabilitation clinics, while the institutional aspect failed to materialise in the absence of relevant legislation which would have made provisions for the dependence itself. There was increased use of the medical framework on the conceptual level, culminating in a 1974 report by the National Board of Health and Welfare. Leaning on the World Health Organisation’s definition of drugs and dependence, the report examined the relationship of tobacco to such key concepts as compulsion, tolerance, withdrawal symptoms, and overdose. The report made clear that smoking was habit-forming, leading to a compulsive use of the substance, that a pause in the supply created withdrawal symptoms, that smokers could present both psychological and physical dependence (increased tolerance and physical symptoms of withdrawal) and that it was also possible for life-threatening conditions to arise as a consequence. All in all, smoking more than met the WHO criteria of ‘dependence’ (Tibblin, 1973, p. 164).

The public health framework

Towards the end of the 1970s, Sweden adopted legislation on declarations of content, health warning messages on tobacco products and marketing regulations. Information and education efforts were extended and new smoking rehabilitation clinics were founded (Nordlund, 2005). The link between smoking and lung cancer was corroborated by new research in the 1980s, and the role was confirmed of nicotine as an addictive substance (Elam, 2014). Such research findings partly drove the setting up of a new government inquiry in 1988 to propose measures to decreasing tobacco consumption. The committee published its report in 1990 (SOU 1990:29). A few years later came the government’s proposal for a new tobacco act (GB, 1992/93:185), which entered into force in 1993 and was at the time the first body of legislation to tackle the smoking problem.

The framing of smoking as a public health problem was already evident in the 1990 public health proposal, which discussed the future tobacco policy in the same breath with alcohol policy and the establishment of a national public health institute (GB, 1990/91:175). Parliamentary debates, too, used the concept of public health to illustrate the extent of the problem and to justify political measures (PB, 1992/93:So45, 1992/93:So47–49, 1992/93:So52, 1992/93:So55–59, 1992/93:So267; PR, 1992/93:117, sp. 81–84, 90, 91 93, 96, 97, 113 & 126; SoU, 1992/93:SoU26; SOU, 1990:29). National and international statistics, as well as the linking to WHO’s definition, also anchored smoking in the realm of public health discourse (PB, 1992/93: So47, 1992/93: So49, 1992/93: So52; M 1992/93: So267; PR, 1992/93:117, sp. 81, 84 & 91).

It was factors such as the extent of the problem and the drastic consequences which rendered smoking the status of a public health issue: death rates were a recurring theme in the accounts of the victims of smoking, which ‘killed as many people as traffic accidents, alcohol, AIDS, and violent crime put together’ (PB, 1992/93: So490, p. 9). This was a ‘quiet global disaster’, something that made tobacco ‘one of the greatest threats against mankind’ (PR, 1992/93:117, sp. 82, p. 72; PB, 1992/93:So45, 1992/93:So47–49, 1992/93:So52, 1992/93:So56–57, 1992/93:So60, 1992/93:So267, 1992/93:So490; PR, 1992/93:117, sp. 84, 91 & 113.). The collectively-oriented responses, many of which had been keenly debated previously, too, came to be increasingly identified as public health measures. This was also in line with the goal of the tobacco inquiry to broaden the focus from ‘efforts aimed at individuals’ (SOU, 1990:29, p. 9). As one MP said in 1993, it was ‘the public health that the tobacco act is to protect’ (PR, 1992/93:117, sp. 90, p. 82).

The status and the shifting motives behind the tobacco monopoly are in many ways telling of how the state conceived of tobacco use. As in several other countries, ever since it was managed by private contractors on government assignments in the 17th century, the tobacco monopoly was motivated primarily by the government’s ambition to control revenue from tobacco trade (Feldman, 2001; Goodman, 1993). The Swedish 1915 state production monopoly and the 1943 state import and market monopoly did not differ in this regard; the economy was the main motive and health arguments played a subordinate role. This did not prevent the Swedish state tobacco monopoly from enjoying the confidence of the state as an enlightening and health-promoting agency, something that contributed to the fact that the harmfulness of smoking for a long time remained a political non-issue (Torell, 2002). The 1960s deregulation, which converted the Swedish Tobacco Monopoly into a state-owned limited company as one of many actors on a free tobacco market, was also motivated by the (misplaced) ambition to increase the tobacco-based tax revenue. The wholesale abolition of the state-owned tobacco company in 1993 when the company became a privately owned enterprise was rather driven by the aim to be able to act free from the tobacco interests in the face of reforms which sought stricter controls of the tobacco consumption (Nordlund, 2005). Among the restrictions that were discussed were age limits, taxation and bans on tobacco vending machines, together with information and propaganda. An advertising ban remained high on the agenda, partly thanks to British research which showed a relationship between advertisements and levels of consumption, and partly as a result of EU and WHO recommendations. Research was on the whole used more commonly to justify the efforts to reform the tobacco policy (PB, 1992/93:So47, 1992/93:So49, 1992/93:So51–52, 1992/93:So55–57, 1992/93:So60, 1992/93:So267, 1992/93:So490; PR 1992/93:117, sp. 85, 91, 104 & 113; SoU, 1992/93:SoU26). That the measures had both concrete goals and aimed to send a political signal is obvious in several contexts: the advertising ban would ‘show the youth how the society felt about tobacco use’ (PB, 1992/93:So47, p. 8); age limits would also contribute to a ‘signalling effect’ (PR, 1992/93:117, sp. 126, p. 115); smoke-free environments were not only a way to combat harmful passive smoking but would also ‘challenge the notion held, for example, by children and teenagers that smoking is acceptable in our society at every turn and at all times’ (SOU 1990:29, p. 102. Also: PR, 1992/93:117, sp. 83 & 91).

Passive smoking now came to take a more focal role in the problem description. It was ‘no longer the private affair of an individual whether he smokes or not’ (PR, 1992/93:117, sp. 84, p. 76). A more prominent focus on passive smoking in public health work also led to increased demands for smoke-free environments (SOU 1990:29, PB, 1992/93:So47–49, 1992/93:So51–52, 1992/93:So54, 1992/93:So56–60, 1992/93:So267; PR, 1992/93:117, sp. 82, 83, 91, 96, 104, 113 & 142; SoU, 1992/93:SoU26). In the long run, passive smoking helped to launch an impressive range of measures from education to regulation. It also proved easier to restrict smoking in public places when smoking declined among the higher socioeconomic groups: ‘the smoking privilege of the powerful’ was not threatened to the same extent as previously, as Nordlund (2005, p. 348) has phrased it.

Nordlund (2005) also maintains that awareness of the addictive properties of nicotine at the end of the 1980s boosted the arguments for government intervention, especially when linked to the dangers of passive smoking. Torell (2002) also argues, albeit somewhat ambiguously, that tobacco use was medicalised during the 1980s. The case became more tangible in the 1990s with established links to drug addiction and biochemical processes. However, as shown above, representations of tobacco use as addictive did not rely on this scientific frame of reference to exist. While this understanding of the problem grew more common in the 1990s, what mattered more was a whole new conceptual apparatus.

The early 1990s emphasis on teenagers was also justified by the fact that early initiation of tobacco use led to a more severe dependence (PB, 1992/93: So45, 1992/93: So49, 1992/93: So51; PR, 1992/93:117, sp. 84). But the dependence was more than just one of the many characteristics of tobacco use; it represented the very core of the problem, standing in the way of the solution that all other measures aimed at (PB, 1992/93: So45, 1992/93: So51, 1992/93: So60, 1992/93: So267, 1992/93: So490; PR, 1992/93:117, sp. 84, 104 & 128). The 1993 speech by one liberal MP also contains the first instance of a fully developed brain disease model of addiction [BDMA] as applied to tobacco use, where the biochemical aspect both underlined the severity of the matter and the need to take any necessary measures:

Nicotine is the addictive substance in tobacco. It impacts a number of receptors in the brain and other areas of the nervous system. Recent research has increased our knowledge about how nicotine affects the so-called reward systems of the brain. These are central to the creation of a pleasurable sensation of smoking (PR, 1992/93:117, sp. 104, p. 95–96).

BDMA functions as a conceptual merger, and tobacco use was at the time recurrently discussed together with alcohol use in terms of similar health risks to be addressed by similar measures (SOU 1990:29; PB, 1992/93: So49; PR, 1992/93:117, sp. 89, 99 & 107; SoU, 1992/93: SoU26). Links to narcotics were also plentiful: tobacco was described as ‘a narcotic substance’, it was said to ‘meet all criteria to be classified as a narcotic’, and was claimed to be ‘as dependence-producing as many currently banned narcotics’ (PR, 1992/93:117, sp. 87, p. 81, 84, & 76. Also: PB, 1992/93:So60: PR, 1992/93:117, sp. 104). There was ‘a strong connection between smoking and drug use’ because ‘there would be no drugs in principle without smoking’, as ‘all drug addicts have entertained smoking as their first vice’ (PR, 1992/93:117, sp. 82, p. 72, 85 & 79). At the same time, towards the end of our study period, few debates addressed concrete medical treatment for this disease. The individual care – rehabilitation – was a highly marginal political question and emerged on only two occasions in the parliamentary debates (PR, 1992/93:117, sp. 90 & 104). This may be because the question was no longer topical; smoking detox was by now an institutionalised treatment measure (Nordlund, 2005).

Discussion

In comparison with the somewhat limited research on the history of tobacco control that exists for other countries, the Swedish example shows some specific features with its rather late legislation, a vague research base in politics (if any), and only occasional and late references to addiction. Another feature is the early discussion of the consequences of passive smoking, albeit generally more often comprehended as an occupational health concern than a strict health problem.

However, based on the limited historical research in this field, it is difficult to determine if Sweden really was so different in terms of, for example, the vague research base in tobacco politics or the very few and late references to addiction or if the difference to other countries is more derived from different interpretations of similar developments. It is for example common even in Swedish research on the history of tobacco regulation to argue that medical research was the main driver: scientifically established links between smoking and cancer, and between passive smoking and cancer, are for example made to explain policy shifts which take into consideration harms to smokers and harms to others; neuroscientific research is then assumed to strengthen addiction as a policy fact. What we have here is a touch of whig history when recent research is treated as true and objective and, as such, as a natural basis for rational policy management while older truths are seen as curious delusions. Scientific studies of a perceived problem’s key components obviously have a bearing on how the phenomenon is portrayed in, for example, the media and political debate, but research may just as well be reactive as proactive. Science-policy research in different fields has also observed covariance which may indicate both evidence-based policy and policy-based evidence (e.g. France & Utting, 2005; Marmot, 2004; Stevens, 2007; Weiss, Murphy-Graham, Petrosino, & Gandhi, 2008). The emphasis of previous historiography on the role of research in driving increasingly restrictive tobacco policies can, therefore, partly be nuanced by the vast body of research which has not transformed into policy, partly by our analysis that several problem descriptions predated their being conceptually recast in a scientific language mould. We, therefore, consider the intensified use of research as a sign of its increased role in the service of political justification rather than as the decisive factor in the development.

The medicalisation of tobacco use suggested by previous research is a complex process of rationalisation which (at least rhetorically) displaces, for example, moral explanations by a specific kind of scientific explanation. It is a biological reductionism of sorts that highlights a niche of a complex phenomenon (Turner, 1987). The power and development of medicalisation depend on the support of the medical profession but the driving forces wax and wane. They can frequently be found in social movements, political needs or economic interests (Conrad, 2007; Keane, 2002; Reith & Dobbie, 2012). A more robust problematisation (and medicalisation) of tobacco use has required that the use be first denormalised. It is therefore only at the end of the 1980s that several trends with long-standing roots come together in a more conclusive medicalisation of tobacco use. Here, substitution treatment is preferred over detoxification, neuroscience has a more prominent role and tobacco consumers are increasingly referred to as unfree because of their dependence (Bailey, 2004; Bell & Keane, 2012; Berridge, 1997, 1998; Brandt, 1991; Chapman & Freeman, 2008; Elam, 2014; Hakkarainen, 2013; Hellman et al., 2016; Hellman, Majamäki, & Hakkarainen, 2014; Hooker & Chapman, 2007).

It is possible to trace a medicalisation of the tobacco issue, but it is neither clear-cut nor progressive nor does it take precedence in the political debate. The irrationality of the tobacco consumer, as a slave to the vice, was recognised long before research introduced the addictive properties of nicotine into the problem description. Comparisons with the misuse of other substances were made early on, and an explicit framework of addiction terminology was in place from the mid-1970s on. The early 1990s added the occasional yet powerful link to the fully developed BDMA model. The key ingredients were already there in the mid-1960s, but it took time for them to be formulated within a more coherent conceptual frame with a terminology borrowed from research on the misuse of other substances.

Such half-hearted medicalisation of tobacco use was never able to conquer the predominantly social construction of the problem which during our study period regarded the smokers as responsible for their health and increasingly also for the health of those around them. The link to dependence and addiction lifted this everyday experience to a new conceptual level with wide-ranging policy consequences only after the study period. If smokers are addicts, smoking is no longer a question to be attributed to individual choice, as the smoker’s will has been disabled (Bailey, 2004). This may have driven the more clear-cut shift from informed choice to harm to others that manifested itself both politically and in legislative terms when the Swedish Tobacco Act was consolidated and revised during the 1990s and the 2000s (Cisneros Örnberg & Sohlberg, 2012). This is where tobacco policy also breaks with the prevalent new public health model which after the war took smoking as one of its main targets, advocating education and life skills over smoking bans. Tobacco policy thus also breaks with individualised health policy – assisted by prevention science – which is making inroads in many areas (Edman, 2018a; Roumeliotis, 2015). Compared to other substance misuse, the institutional medicalisation of tobacco use came very late. Smoking has largely remained unopposed by the kind of public mass movements that emerged in the mid-19th century to fight alcohol and which were linked to such game-changing social questions as poverty and franchise (Edman, 2015). Nor has opposition to smoking been able to assume a symbolic value similar to the fight against drugs during the post-war era (Edman, 2013). The health argument that has steered the anti-smoking sentiments in the past decades has rather been inspired by general health awareness trends and by increasingly influential notions of dependence and public health.

But if we are to understand the role of the medicalised construction of the tobacco problem in policy action at the end of the 20th century, we need to keep the empirical differences in order. While a certain meeting of the minds has taken place with regard to different substance misuse – which reaches its self-fulfilling theoretical culmination in BDMA – there are nevertheless crucial differences between a nicotinist and, for example, an alcoholic. The alcohol disease has long, but mainly in the post-war period, been described in terms of certain individuals’ biological predisposition towards alcohol misuse (Edman, 2018b), whereas nicotinism pays more attention to the addictive tobacco than the genetically peculiar tobacco user. Attempts in the 1950s to define a genetic predisposition to tobacco misuse has in line with this supposedly self-evident problem description by Nordlund (2005, p. 337) been characterised as ‘ludicrous’. But is it more ludicrous to suppose that some people are predisposed to tobacco misuse than to the misuse of alcohol? The question merits some thought, as attention to addictive substances as opposed to dependence-oriented people gives rise to radically different policy effects. For example, alcohol is in extreme cases described in accordance with the paradigm of alcoholism as an almost harmless product that should, however, be avoided by certain people (Edman, 2018b). Correspondingly, tobacco is represented as a product that is indeed dangerous, but equally dangerous to everyone. The problem descriptions thus lead to potentially different policy outcomes: the mould of alcoholism has been supported by the alcohol industry, which lets alcohol flow free (Burnham, 1992; Room, 2011; Rubin, 1979). The tobacco industry has at the same time fought hard to reject claims of the addictive effects of nicotine (e.g. Henningfield, Rose, & Zeller, 2006). The fact that the Swedish alcohol monopoly sells roughly the same amount of alcohol converted to pure alcohol in the 2010s as it did in the mid-1970s (Folkhälsomyndigheten, 2014), while cigarette sales have dropped radically during the same period (Nordlund, 2005), probably speaks to the importance of choosing the right model of dependence.

Disclosure statement

No potential conflict of interest was reported by the authors.