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Use of snus and acute myocardial infarction: pooled analysis of eight prospective observational studies

  • CARDIOVASCULAR DISEASE
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Abstract

The use of snus (also referred to as Scandinavian or Swedish moist smokeless tobacco), which is common in Sweden and increasing elsewhere, is receiving increasing attention since considered a tobacco smoke “potential reduction exposure product”. Snus delivers a high dose of nicotine with possible hemodynamic effects, but its impact on cardiovascular morbidity and mortality is uncertain. The aim of this study was to investigate whether snus use is associated with risk of and survival after acute myocardial infarction (AMI). Data from eight prospective cohort studies set in Sweden was pooled and reanalysed. The relative risk of first time AMI and 28-day case-fatality was calculated for 130,361 men who never smoked. During 2,262,333 person-years of follow-up, 3,390 incident events of AMI were identified. Current snus use was not associated with risk of AMI (pooled multivariable hazard ratio 1.04, 95 % confidence interval 0.93 to 1.17). The short-term case fatality rate appeared increased in snus users (odds ratio 1.28, 95 % confidence interval 0.99 to 1.68). This study does not support any association between use of snus and development of AMI. Hence, toxic components other than nicotine appear implicated in the pathophysiology of smoking related ischemic heart disease. Case fatality after AMI is seemingly increased among snus users, but this relationship may be due to confounding by socioeconomic or life style factors.

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Abbreviations

AMI:

Acute myocardial infarction

BMI:

Body mass index

CI:

Confidence intervals

HR:

Hazard ratio

ICD:

International Classification of Diseases

IHD:

Ischemic heart disease

OR:

Odds ratio

References

  1. Lambe M. Swedish snus for tobacco harm reduction. Lancet. 2007;370(9594):1206–7. (1206; author reply).

    Article  PubMed  Google Scholar 

  2. Foulds J, Kozlowski L. Snus–what should the public-health response be? Lancet. 2007;369(9578):1976–8.

    Article  PubMed  Google Scholar 

  3. European Commission. Health effects of smokeless tobacco products: Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR). Brussels. 2007.

  4. Holm LE, Fisker J, Larsen BI, Puska P, Halldorsson M. Snus does not save lives: quitting smoking does! Tob control. 2009;18(4):250–1.

    Article  PubMed  Google Scholar 

  5. Stenbeck M, Hagquist C, Rosen M. The association of snus and smoking behaviour: a cohort analysis of Swedish males in the 1990s. Addiction (Abingdon, England). 2009;104(9):1579–85.

    Article  Google Scholar 

  6. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction (Abingdon, England). 2003;98(9):1183–9.

    Article  Google Scholar 

  7. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol. 2008;9(7):667–75.

    Article  PubMed  Google Scholar 

  8. Nordenvall C, Nilsson PJ, Ye W, Nyren O. Smoking, snus use and risk of right- and left-sided colon, rectal and anal cancer: a 37-year follow-up study. Int J Cancer. 2011;128(1):157–65.

    Article  PubMed  CAS  Google Scholar 

  9. England LJ, Levine RJ, Mills JL, Klebanoff MA, Yu KF, Cnattingius S. Adverse pregnancy outcomes in snuff users. Am J Obstet Gynecol. 2003;189(4):939–43.

    Article  PubMed  Google Scholar 

  10. Wikstrom AK, Cnattingius S, Galanti MR, Kieler H, Stephansson O. Effect of Swedish snuff (snus) on preterm birth. BJOG. 2010;117(8):1005–10.

    Article  PubMed  Google Scholar 

  11. Wikstrom AK, Cnattingius S, Stephansson O. Maternal use of Swedish snuff (snus) and risk of stillbirth. Epidemiology (Cambridge, Mass). 2010;21(6):772–8.

    Article  Google Scholar 

  12. Holm H, Jarvis MJ, Russell MA, Feyerabend C. Nicotine intake and dependence in Swedish snuff takers. Psychopharmacology. 1992;108(4):507–11.

    Article  PubMed  CAS  Google Scholar 

  13. Benowitz NL. The role of nicotine in smoking-related cardiovascular disease. Prev Med. 1997;26(4):412–7.

    Article  PubMed  CAS  Google Scholar 

  14. Huhtasaari F, Asplund K, Lundberg V, Stegmayr B, Wester PO. Tobacco and myocardial infarction: is snuff less dangerous than cigarettes? BMJ (Clinical research ed.). 1992;305(6864):1252–6.

    Article  CAS  Google Scholar 

  15. Huhtasaari F, Lundberg V, Eliasson M, Janlert U, Asplund K. Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men. J Am Coll Cardiol. 1999;34(6):1784–90.

    Article  PubMed  CAS  Google Scholar 

  16. Hergens MP, Ahlbom A, Andersson T, Pershagen G. Swedish moist snuff and myocardial infarction among men. Epidemiology (Cambridge, Mass). 2005;16(1):12–6.

    Article  Google Scholar 

  17. Johansson SE, Sundquist K, Qvist J, Sundquist J. Smokeless tobacco and coronary heart disease: a 12-year follow-up study. Eur J Cardiovasc Prev Rehabil. 2005;12(4):387–92.

    Article  PubMed  Google Scholar 

  18. Hergens MP, Alfredsson L, Bolinder G, Lambe M, Pershagen G, Ye W. Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men. J Intern Med. 2007;262(3):351–9.

    Article  PubMed  Google Scholar 

  19. Wennberg P, Eliasson M, Hallmans G, Johansson L, Boman K, Jansson JH. The risk of myocardial infarction and sudden cardiac death amongst snuff users with or without a previous history of smoking. J Intern Med. 2007;262(3):360–7.

    Article  PubMed  CAS  Google Scholar 

  20. Haglund B, Eliasson M, Stenbeck M, Rosen M. Is moist snuff use associated with excess risk of IHD or stroke? A longitudinal follow-up of snuff users in Sweden. Scand J public Health. 2007;35(6):618–22.

    Article  PubMed  Google Scholar 

  21. Hansson J, Pedersen NL, Galanti MR, Andersson T, Ahlbom A, Hallqvist J, Magnusson C. Use of snus and risk for cardiovascular disease: results from the Swedish Twin Registry. J Intern Med. 2009;265(6):717–24.

    Article  PubMed  CAS  Google Scholar 

  22. Janzon E, Hedblad B. Swedish snuff and incidence of cardiovascular disease. A population-based cohort study. BMC Cardiovasc Disord. 2009;9:21.

    Article  PubMed  Google Scholar 

  23. Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health. 1994;84(3):399–404.

    Article  PubMed  CAS  Google Scholar 

  24. Carlsson F, Merlo J, Lindstrom M, Ostergren PO, Lithman T. Representativity of a postal public health questionnaire survey in Sweden, with special reference to ethnic differences in participation. Scand J public health. 2006;34(2):132–9.

    Article  PubMed  Google Scholar 

  25. Eriksson M, Holmgren L, Janlert U, Jansson JH, Lundblad D, Stegmayr B, Soderberg S, Eliasson M. Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–2009. J Intern Med. 2011;269(2):219–31.

    Article  PubMed  CAS  Google Scholar 

  26. Manjer J, Carlsson S, Elmstahl S, Gullberg B, Janzon L, Lindstrom M, Mattisson I, Berglund G. The Malmo diet and cancer study: representativity, cancer incidence and mortality in participants and non-participants. Eur J Cancer Prev. 2001;10(6):489–99.

    Article  PubMed  CAS  Google Scholar 

  27. Alfredsson L, Hammar N, Fransson E, de Faire U, Hallqvist J, Knutsson A, Nilsson T, Theorell T, Westerholm P. Job strain and major risk factors for coronary heart disease among employed males and females in a Swedish study on work, lipids and fibrinogen. Scand J Work Environ Health. 2002;28(4):238–48.

    Article  PubMed  Google Scholar 

  28. Bellocco R, Jia C, Ye W, Lagerros YT. Effects of physical activity, body mass index, waist-to-hip ratio and waist circumference on total mortality risk in the Swedish National March Cohort. Eur J Epidemiol. 2010;25(11):777–88.

    Article  PubMed  Google Scholar 

  29. Lichtenstein P, Sullivan PF, Cnattingius S, Gatz M, Johansson S, Carlstrom E, Bjork C, Svartengren M, Wolk A, Klareskog L, et al. The Swedish Twin Registry in the third millennium: an update. Twin Res Hum Genet. 2006;9(6):875–82.

    Article  PubMed  Google Scholar 

  30. Hansson J, Galanti MR, Magnusson C, Hergens MP. Weight gain and incident obesity among male snus users. BMC Public Health. 2011;11:371.

    Article  PubMed  Google Scholar 

  31. Norberg M, Wall S, Boman K, Weinehall L. The vasterbotten intervention programme: background, design and implications. Glob Health Action. 2010; 3:4643. doi:10.3402/gha.v3i0.4643.

  32. Eliasson M, Asplund K, Evrin PE, Lundblad D. Relationship of cigarette smoking and snuff dipping to plasma fibrinogen, fibrinolytic variables and serum insulin. The Northern Sweden MONICA Study. Atherosclerosis. 1995;113(1):41–53.

    Article  PubMed  CAS  Google Scholar 

  33. Lundqvist G, Sandstrom H, Ohman A, Weinehall L. Patterns of tobacco use: a 10-year follow-up study of smoking and snus habits in a middle-aged Swedish population. Scand J Public Health. 2009;37(2):161–7.

    Article  PubMed  Google Scholar 

  34. Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K. Evolving patterns of tobacco use in northern Sweden. J Intern Med. 2003;253(6):660–5.

    Article  PubMed  CAS  Google Scholar 

  35. Furberg H, Lichtenstein P, Pedersen NL, Bulik C, Sullivan PF. Cigarettes and oral snuff use in Sweden: prevalence and transitions. Addiction (Abingdon, England). 2006;101(10):1509–15.

    Article  Google Scholar 

  36. Hammar N, Alfredsson L, Rosen M, Spetz CL, Kahan T, Ysberg AS. A national record linkage to study acute myocardial infarction incidence and case fatality in Sweden. Int J Epidemiol. 2001;30(Suppl 1):S30–4.

    Article  PubMed  Google Scholar 

  37. Lee PN. Circulatory disease and smokeless tobacco in Western populations: a review of the evidence. Int J Epidemiol. 2007;36(4):789–804.

    Article  PubMed  Google Scholar 

  38. Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis. BMJ (Clinical research ed.). 2009;339:b3060.

  39. Galobardes B, Lynch J, Smith GD. Measuring socioeconomic position in health research. Br Med Bull. 2007;81–82:21–37.

    Article  PubMed  Google Scholar 

  40. Peltonen M, Rosen M, Lundberg V, Asplund K. Social patterning of myocardial infarction and stroke in Sweden: incidence and survival. Am J Epidemiol. 2000;151(3):283–92.

    Article  PubMed  CAS  Google Scholar 

  41. Engström K, Magnusson C, Galanti MR. Socio-demographic, lifestyle and health characteristics among snus users and dual tobacco users in Stockholm County Sweden. BMC Public Health. 2010;10:619.

    Article  PubMed  Google Scholar 

  42. Corrao G, Rubbiati L, Bagnardi V, Zambon A, Poikolainen K. Alcohol and coronary heart disease: a meta-analysis. Addiction (Abingdon, England). 2000;95(10):1505–23.

    Article  CAS  Google Scholar 

  43. Yashima M, Ohara T, Cao JM, Kim YH, Fishbein MC, Mandel WJ, Chen PS, Karagueuzian HS. Nicotine increases ventricular vulnerability to fibrillation in hearts with healed myocardial infarction. Am J Physiol Heart Circ Physiol. 2000;278(6):H2124–33.

    PubMed  CAS  Google Scholar 

  44. Ohara T, Yashima M, Hamzei A, Favelyukis M, Park A, Kim YH, Mandel WJ, Chen PS, Karagueuzian HS. Nicotine Increases Spatiotemporal Complexity of Ventricular Fibrillation Wavefront on the Epicardial Border Zone of Healed Canine Infarcts. J Cardiovasc Pharmacol Ther. 1999;4(2):121–7.

    Article  PubMed  CAS  Google Scholar 

  45. Mehta MC, Jain AC, Mehta A, Billie M. Cardiac Arrhythmias Following Intravenous Nicotine: experimental Study in Dogs. J Cardiovasc Pharmacol Ther. 1997;2(4):291–8.

    Article  PubMed  CAS  Google Scholar 

  46. Martin JS, Beck DT, Gurovich AN, Braith RW. The acute effects of smokeless tobacco on central aortic blood pressure and wave reflection characteristics. Exp Biol Med (Maywood). 2010;235(10):1263–8.

    Article  CAS  Google Scholar 

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Acknowledgments

We thank Kontie Moussa, Eleonor Fransson, Annika Gustavsson and Tomas Andersson for their contributions to this paper. This study was funded by grants from the Stockholm County Council, the Swedish Research Council (grant n o. 2007-3185), National Institute of Public Health (grant no. 2008/188), and the Swedish Council for Working Life and Social Research (grant no. 2010-0546). The Northern Sweden MONICA study was supported by grants from Norrbotten and Västerbotten County Councils, the Swedish Research Council, the Joint Committee of Northern Sweden Health Care Region (Visare Norr), the Heart and Chest Foundation, the Stroke fund, King Gustaf V’s and Queen Victoria’s Foundation, the Vårdal Foundation and the Social Sciences Research Council. The Wolf study was supported by the Swedish Council for Working Life and Social Research.

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The authors declare that they have no conflict of interest.

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Correspondence to Jenny Hansson.

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Hansson, J., Galanti, M.R., Hergens, MP. et al. Use of snus and acute myocardial infarction: pooled analysis of eight prospective observational studies. Eur J Epidemiol 27, 771–779 (2012). https://doi.org/10.1007/s10654-012-9704-8

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  • DOI: https://doi.org/10.1007/s10654-012-9704-8

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