The burden of mortality from smoking: comparing Sweden with other countries in the European Union

Risk and predictors of fractures in early rheumatoid arthritis - A long term follow up study of an inception cohort

OBJECTIVES

To examine the risk of fractures in a cohort of patients with newly diagnosed rheumatoid arthritis (RA), compared to the background population, and predictors of fractures detectable early in RA.

METHODS

An inception cohort of patients with RA (N = 233; 164 women/69 men, recruited 1995-2005) was evaluated according to a structured program, including repeated clinical assessments and measures of bone mineral density (BMD), from diagnosis to 10 years later. Matched population controls were identified using the national census register. Fractures through 2019 were identified based on ICD codes. Cox regression models were used to assess the risk of fractures in RA patients compared with controls, and for assessment of potential predictors for fractures in the RA population.

RESULTS

RA patients had an increased risk of fractures (fully adjusted hazard ratio (HR) 1.52, 95 % CI 1.13; 2.06). In the RA cohort, high age, low body mass index, and low BMD were significant baseline predictors of future fractures in multivariate analyses, but baseline RA disease characteristics were not. Worse disability (i.e. higher Health Assessment Questionnaire (HAQ) scores) over time was significantly associated with increased risk of fractures (age-sex-adjusted HR 1.33 per SD, 95 % CI 1.09; 1.63) and there was an inverse association between BMD Z-scores over time and fractures.

CONCLUSION

Patients with RA had higher risk of fractures than controls. Fracture risk was related to BMD at baseline and over time in patients with RA. In addition, worse disability (measured by HAQ) over time was associated with higher risk of fractures.

Cancer mortality by country of birth and cancer type in Sweden: A 25-year registry-based cohort study

Numerous studies have reported lower overall cancer mortality rates among immigrants compared to native populations. However, limited information exists regarding cancer mortality among immigrants based on specific birth countries and cancer types. We used population-based registries and followed 10 million individuals aged 20 years or older in Sweden between 1992 and 2016. The Cox proportional hazard model was used to explore the disparities in cancer mortality by country of birth and cancer type, stratified by gender. Age-standardized mortality rates were also computed using the world standard population. Hazard ratio (HR) of all-site cancer was slightly lower among immigrants (males: HRm = 0.97: 95% confidence interval: 0.95, 0.98; females: HRf = 0.93: 0.91, 0.94) than Swedish-born population. However, the immigrants showed higher mortality for infection-related cancers, including liver (HRf = 1.10: 1.01, 1.19; HRm = 1.10: 1.02, 1.17), stomach (HRf = 1.39: 1.31, 1.49; HRm = 1.33: 1.26, 1.41) cancers, and tobacco-related cancers, including lung (HRm = 1.44: 1.40, 1.49), and laryngeal cancers (HRm = 1.47: 1.24, 1.75). The HR of mesothelioma was also significantly higher in immigrants (HRf = 1.44: 1.10, 1.90). Mortality from lung cancer was specifically higher in men from Nordic (HRm = 1.41: 1.27, 1.55) and non-Nordic Europe (HRm = 1.49: 1.43, 1.55) countries and lower in Asian (HRm = 0.78: 0.66, 0.93) and South American men (HRm = 0.70: 0.57, 0.87). In conclusion, there are large variations in cancer mortality by country of birth, and cancer type and require regular surveillance. Our detailed analyses lead to some novel findings such as excess mortality rate of mesothelioma and laryngeal cancers in Immigrants in Sweden. A targeted cancer prevention program among immigrants in Sweden is needed.

Burden of current and past smoking across 28 European countries in 2017: A cross-sectional analysis

INTRODUCTION

Most studies use the prevalence of current smoking as an indicator to quantify the burden of smoking. However, length and intensity of smoking, as well as time since cessation for former smokers are also known to impact smoking-related health risks. The aim of this study was to quantify and compare the burden of smoking across the European Union (EU) using a range of smoking burden indicators.

METHODS

We conducted a cross-sectional analysis using data from the March 2017 Eurobarometer 87.1 (n=27901, people aged ≥15 years) in 28 European Union Member States (EU MS) and the Tobacco Control Scale. We defined five indicators of smoking burden including the prevalence of current and ever smoking, length of smoking, pack-years, and discounted pack-years, and ranked EU MS by each indicator. Two-level linear and logistic regressions were performed to assess the association between these indicators and sociodemographic and tobacco policy factors.

RESULTS

Wide variations across the EU countries were observed in all smoking burden indicators. While some MS ranked consistently high (e.g. Greece, France) or consistently low (e.g. Ireland, United Kingdom) in all indicators, we found substantial discrepancies in ranking depending on the indicator used for MS such as Malta, Denmark, Finland and the Netherlands. All indicators of smoking burden were lower among women and respondents without financial difficulties; however, the magnitude of those inequalities varied two-fold among the different indicators.

CONCLUSIONS

Using a range of smoking burden indicators can be more informative than relying on prevalence alone. Our analysis highlights the limitations of relying solely on prevalence of current smoking to estimate the burden of smoking and the potential value of more nuanced indicators. We recommend that multiple and more nuanced indicators that consider former smokers, intensity and duration of smoking should be utilized to monitor tobacco use and evaluate tobacco control policies.

Clinical course of Crohn's disease in a population-based cohort in Uppsala County followed for 10 years

BACKGROUND AND AIMS

There is a shortage of studies describing the outcome of patients with Crohn's disease (CD) where both biological therapy and immunomodulators (IMMs) have been available. The aim of the present study was to describe the clinical course of the disease, the use of drugs, the need for surgery and mortality in a prospectively recruited population-based cohort of patients followed for 10 years.

METHODS

All patients diagnosed with CD in the County of Uppsala in Sweden 2005-2009 were prospectively recruited and followed until the end of 2019. The medical notes were scrutinised and relevant information collected.

RESULTS

One hundred and fifty-four patients covering all age groups were diagnosed with CD and 145 (94.2%) could be followed for 10 years or until death. Nine patients were lost to follow up. The following drugs were used: 5-ASA 83%, steroids 84%, IMMs 69% and biologicals 23%. The proportion of penetrating disease increased from 9.7 to 14.5%. Primary bowel resections were performed in 22% of the patients, and none of these had any secondary surgery because of recurrent or progressive disease during the observation time. Twelve patients (7.8%) died during the follow up, and one of these because of a small bowel carcinoma.

CONCLUSIONS

In the present study, the clinical course of CD was similar to previous reports during the first year after diagnosis, but the following years were considerably more stable with moderate increase of intestinal damage and totally a low frequency of surgery and no repeated surgery.

International Differences in the Risk of Death from Smoking and Obesity: The Case of the United States and Finland

Despite much interest in the health risks associated with behavioral factors, little is known about whether individuals residing in different countries experience a different set of risks. International comparisons of the death risks from major behavioral factors can shed light on whether features of health systems and epidemiological histories modify the health effects of risky behaviors. We used nationally representative samples and mortality linkages spanning the 1971-2014 period from the United States and Finland to examine cross-national differences in the risks of death from cigarette smoking and obesity. We evaluated both current and former smoking and current and prior obesity. In 1990, the approximate midpoint of our study, the death risks from current smoking were about 55% higher in U.S. women compared to Finnish women, but similar for men in the two countries. Death risks from smoking significantly increased over the period for women in both countries and there was no parallel increase in risks among men. Death risks from obesity did not significantly differ in the two countries and no significant trend in the risks were detected in either country. Reasons for the relatively high and increasing risks from smoking among American women warrant further evaluation.

The contribution of alcohol consumption and smoking to educational inequalities in life expectancy among Swedish men and women during 1991-2008

Objectives

To assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden.

Methods

We used register data on the Swedish population at ages 30–74 during 1991–2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality.

Results

Alcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking.

Conclusions

Smoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.

Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment

BACKGROUND

Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models.

METHODS

For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported.

RESULTS

Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases).

CONCLUSION

Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

Investigating the effect of banning non-reduced ignition propensity cigarettes on fatal residential fires in Sweden

BACKGROUND

Annually, 100 people die as a result of residential fires in Sweden and almost a third of the fatal fires are known to be caused by smoking. In an attempt to reduce the occurrence of these events, reduced ignition propensity (RIP) cigarettes have been developed. They are designed to reduce the risk of fire by preventing the cigarette from burning through the full length when left unattended. In November 2011, a ban was introduced, forbidding the production and sale of all non-RIP cigarettes in all member states of the European Union, including Sweden.

METHODS

Monthly data on all recorded residential fires and associated fatalities in Sweden from January 2000 to December 2013 were analyzed using an interrupted time series design. The effect of the intervention [in relative risk (RR)] was quantified using generalised additive models for location, shape and scale.

RESULTS

There were no statistically significant intervention effects on residential fires (RR 0.95 [95% CI: 0.89-1.01]), fatal residential fires (RR 0.99 [95% CI: 0.80-1.23]), residential fires where smoking was a known cause (RR 1.10 [95% CI: 0.95-1.28]) or fatal residential fires where smoking was a known cause (RR 0.92 [95% CI: 0.63-1.35]).

CONCLUSION

No evidence of an effect of the ban on all non-RIP cigarettes on the risk of residential fires in Sweden was found. The results may not be generalisable to other countries.

Habits and attitudes of first-year female students at Warmia and Mazury University: a call for implementing health education programme at universities

INTRODUCTION

Entering university frequently brings about considerable changes in the students' lifestyle, which often affect negatively their health. Therefore, it seems to be of great importance to promote pro-health habits and attitudes particularly among 1st-year-students and thus, it is necessary to accurately assess their lifestyles and needs in this regard.

AIM

The aim of the study was to assess the habits and attitudes towards healthy lifestyle of 762 first-year female students enrolled at the University of Warmia and Mazury in Olsztyn so as to detect health risks and ultimately present the need for remedial measures.

METHODS

Female students were randomly selected from all the groups attending obligatory physical education classes. The students filled in an anonymous questionnaire, which contained questions referring to their physical activity, nutrition, tobacco and alcohol use, and stress.

RESULTS

The research demonstrated a worrisome picture of the students' habits and attitudes with regard to health. It showed that the female students took keener interest in daily body care than in proper nutrition and an adequate level of physical activity. What is also alarming is the excessive amount of alcohol they consumed on a regular basis.

CONCLUSIONS

The research findings call for a specially designed pro-health programme to be implemented during the time of the studies in order to raise the female students' awareness of leading a health-conscious lifestyle.

The impact of life tables adjusted for smoking on the socio-economic difference in net survival for laryngeal and lung cancer

BACKGROUND

Net survival is a key measure in cancer control, but estimates for cancers that are strongly associated with smoking may be biased. General population life tables represent background mortality in net survival, but may not adequately reflect the higher mortality experienced by smokers.

METHODS

Life tables adjusted for smoking were developed, and their impact on net survival and inequalities in net survival for laryngeal and lung cancers was examined.

RESULTS

The 5-year net survival estimated with smoking-adjusted life tables was consistently higher than the survival estimated with unadjusted life tables: 7% higher for laryngeal cancer and 1.5% higher for lung cancer. The impact of using smoking-adjusted life tables was more pronounced in affluent patients; the deprivation gap in 5-year net survival for laryngeal cancer widened by 3%, from 11% to 14%.

CONCLUSIONS

Using smoking-adjusted life tables to estimate net survival has only a small impact on the deprivation gap in survival, even when inequalities are substantial. Adjusting for the higher, smoking-related background mortality did increase the estimates of net survival for all deprivation groups, and may be more important when measuring the public health impact of differences or changes in survival, such as avoidable deaths or crude probabilities of death.

Systematic review of Swedish snus for smoking cessation based on primary subject data from randomised clinical trials

Introduction: The ability of Swedish snus to serve as a smoking cessation aid has been documented in several observational, population surveys from Scandinavia, but randomised clinical trials provide more reliable information on efficacy. Aims: To perform a systematic review and meta-analysis of randomised clinical trials of Swedish snus as an aid to smoking cessation. Methods: Literature searches were conducted in MedLine, Cochrane Library, and Embase to identify relevant clinical trials. The primary outcome was defined as biologically confirmed smoking cessation during around six months. Meta-analyses based on primary subject data tested for effect of allocated treatment as well as selected baseline characteristics. Results: There were two relevant clinical trials, one conducted at five sites in the US (n = 250), the other at two sites in Serbia (n = 319). Based on the primary outcome, success was higher in the treated group in both Serbia (5.7% vs 1.9%) and the US (4.0% vs 1.6%). Meta-analysis estimated the relative success rate at 2.83 (95% CI 1.03–7.75), which was of borderline significance (exact p = 0.06, chi-squared p = 0.03). For smoking cessation in the last 4 weeks of each study, rates were 12.4% for snus and 6.6% for placebo (RR 1.86, 95% CI 1.09-3.18). Efficacy of snus was not clearly related to any baseline characteristic. Conclusions: Swedish snus increased quit rates similarly in US and Serbia. These results confirm and extend previous information based on observational population surveys.

Adolescent elite athletes' cigarette smoking, use of snus, and alcohol

The purpose was to examine cigarette smoking, use of snus, alcohol, and performance-enhancing illicit drugs among adolescent elite athletes and controls, and possible gender and sport group differences. First-year students at 16 Norwegian Elite Sport High Schools (n = 677) and two randomly selected high schools (controls, n = 421) were invited to participate. Totally, 602 athletes (89%) and 354 (84%) controls completed the questionnaire. More controls than athletes were smoking, using snus, and drinking alcohol. Competing in team sports was associated with use of snus [odds ratio = 2.8, 95% confidence interval (CI) 1.6 to 4.7] and a similar percentage of male and female handball (22.2% vs 18.8%) and soccer players (15.7% vs 15.0%) reported using snus. For controls, not participating in organized sport was a predictor for smoking (odds ratio = 4.9, 95% CI 2.2 to 10.9). Female athletes were more prone to drink alcohol than males (46.3% vs 31.0%, P < 0.001). Only, 1.2% athletes and 2.8% controls reported use of performance-enhancing illicit drugs. In conclusion, use of legal drugs is less common among athletes, but this relationship depends on type of sport and competition level. The association between team sports and use of snus suggests that sport subcultures play a role.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Seven Year Follow-up of Smoking Cessation with Smokeless Tobacco

This study evaluated the tobacco use status of 63 subjects seven years after enrollment in a single-intervention smoking cessation study employing smokeless tobacco (SLT) as a nicotine substitute. Information about tobacco use and cessation attempts was obtained in interviews. The duration of follow-up and of smoke-free periods were derived from the date of the subject's enrollment and were expressed as person-years (p-y). Because the study focused on the use of SLT for smoking cessation, subjects who used SLT to quit were invited to return for verification (less than 10 parts per million of carbon monoxide in expired air). Follow-up was completed on 62 of 63 original subjects, classified according to tobacco use status at the end of the initial study. Of the 16 subjects who had quit smoking using SLT at one year, 12 were smoke-free at seven years. For all 16 subjects there was 106 p-y of follow-up, 97 (92%) of which were smoke-free. Of six subjects who had quit smoking at one year by a means other than SLT, four were smoke-free at seven years. This entire group had 42 p-y of follow-up, 34 (81%) of which were smoke-free. Of the 41 subjects who were smoking at one year, 12 had quit smoking by the seven-year mark, three of these subjects by using SLT. Total follow-up for this group was 284 p-y, of which 26 (9%) were smoke-free. Although the study is small, the long-term success rate of this pilot trial compares favorably with other cessation studies.

Two-Dimensional Mortality Data: Patterns and Projections

Patterns and trends in late-life mortality are of growing financial importance. The growth in pension liabilities, both public and private, are of crucial interest to governments, insurers and companies with defined benefit pension schemes. This paper explores the patterns in international mortality data, and draws important lessons for actuaries in the United Kingdom.

'These things don't happen in Greece': a qualitative study of Greek young people's attitudes to smoking, secondhand smoke and the smokefree legislation

Greece has the highest smoking prevalence in the European Union, with adolescents having high levels of exposure to secondhand smoke (SHS). In July 2009, national smokefree legislation was implemented in Greece. This study explored Greek young people's attitudes to smoking, SHS and the impending legislation. Semi-structured qualitative interviews were undertaken with 11 groups of 14- to 16-year-old smokers and non-smokers in May and June 2009. Participants described social worlds in which smoking and exposure to SHS were viewed as normal and acceptable. There was little awareness of the health risks of SHS. Smoking was perceived to be both an inherent part of socializing and highly addictive. The 'right' to smoke in public places was thus viewed as greater than that of not being exposed to SHS. There was limited awareness of the impending smokefree legislation. Participants drew on their experience of previous legislation, the perceived rebellious Greek character, and their cynicism about the government in concluding that the legislation would be ineffective. The perceived social norms around smoking and SHS combined with a poor understanding of the health risks and negative attitudes about the impending legislation help to explain the subsequent limited impact of the Greek smokefree legislation.

Outcome expectations and use of smokeless tobacco (snus): a cross-sectional study among young Norwegian snus users

In this study, measures of outcome expectancies related to use of snus (wet snuff) were used to predict reported frequency of snus use. Data stem from a nation-wide survey in Norway among 16- to 20-year-olds. Only users of snus were included in the statistical analyses (n = 589). The main outcome measure, frequency of snus use, was measured as a categorical variable - occasional, weekly and daily use. Four dimensions of outcome expectancies (mood regulation, smoking control, weight control and negative health outcomes) were measured and confirmed in a confirmatory factor analysis. Informants tended to believe that snus use is harmful to health, but still they supported the idea of snus as a way to control own cigarette smoking. In a SEM model, two of the four dimensions of outcome expectancies turned out to be particularly significant predictors of frequency of snus use - mood regulation and smoking control. No significant interactions with gender were found. Males scored higher than females on "mood regulation", and "smoking control", while females scored higher than males on "negative health outcomes". If more smokers were convinced that snus use is a less harmful alternative, more of them might start using snus, not only because there is some association between health outcome expectancies and snus use, but also because snus use by many is perceived as a remedy to stop smoking and as a way to gain some of the mood regulation benefits which are usually associated with smoking.

Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark

OBJECTIVE

To determine whether the repeatedly observed low risk of ulcerative colitis after appendicectomy is related to the appendicectomy itself or the underlying morbidity, notably appendicitis or mesenteric lymphadenitis.

DESIGN

Nationwide cohort studies.

SETTING

Sweden and Denmark.

PARTICIPANTS

709 353 Swedish (1964-2004) and Danish (1977-2004) patients who had undergone appendicectomy were followed up for subsequent ulcerative colitis. The impact of appendicectomy on risk was also studied in 224 483 people whose parents or siblings had inflammatory bowel disease.

MAIN OUTCOME MEASURES

Standardised incidence ratios and rate ratios as measures of relative risk.

RESULTS

During 11.1 million years of follow-up in the appendicectomy cohort, 1192 patients developed ulcerative colitis (10.8 per 100 000 person years). Appendicectomy without underlying inflammation was not associated with reduced risk (standardised incidence ratio 1.04, 95% confidence interval 0.95 to 1.15). Before the age of 20, however, appendicectomy for appendicitis (0.45, 0.39 to 0.53) or mesenteric lymphadenitis (0.65, 0.46 to 0.90) was associated with significant risk reduction. A similar pattern was seen in those with affected relatives, whose overall risk of ulcerative colitis was clearly higher than the background risk (1404 observed v 446 expected; standardised incidence ratio 3.15, 2.99 to 3.32). In this cohort, appendicectomy without underlying appendicitis did not modify risk (rate ratio 1.04, 0.66 to 1.55, v no appendicectomy), while risk after appendicectomy for appendicitis was halved (0.49, 0.31 to 0.74).

CONCLUSIONS

In individuals with or without a familial predisposition to inflammatory bowel disease, appendicitis and mesenteric lymphadenitis during childhood or adolescence are linked to a significantly reduced risk of ulcerative colitis in adulthood. Appendicectomy itself does not protect against ulcerative colitis.

Subjective attractiveness and perceived trendiness in smoking and snus use: a study among young Norwegians

In Norway, there has been a decline in smoking among adults and young people, but there has also been an increase in the use of snus, particularly among young males. Among females, snus use is less common. This study examines to what extent subjective attractiveness (SA) (the individual's personal opinion regarding how attractive a person who smokes/uses snus is) and perceived trendiness (PT) (the individual's impressions of how popular smoking/use of snus is) may contribute to explaining current trends in smoking and snus use among young people in Norway. Data were collected from a national representative sample of 2400 young people (age 16-20) by telephone interviews. Among males, regular smokers were also likely to be regular snus users and vice versa. SA and PT were significant predictors of their respective behaviours (smoking and snus use) and in some cases of the other behaviour. Smoking and snus use were perceived as unattractive, while snus use was perceived to be trendier than smoking. Males, more than females, perceived snus use to be attractive and trendy. This pattern is partly consistent with current changes in tobacco use in the Norwegian population.

Telomere length is associated with obesity parameters but with a gender difference

Cardiovascular disease (CVD) and obesity have been coupled to short telomere length in peripheral blood. The biological background to this observation is not obvious from the literature. In this study we have analyzed a large set of known risk factors for CVD in relation to telomere length in blood cells on a merged cohort of 989 individuals recruited in the Malmö Diet and Cancer Cohort (MDCC) and the Northern Sweden MONICA project. We found a significant or borderline association between obesity parameters and telomere length in women after age and center adjustments (BMI: r = -0.106, P = 0.021, weight: r = -0.087, P = 0.060, waist circumference: r = -0.099, P = 0.032, hip circumference: r = -0.128, P = 0.005). In men, a positive borderline correlation to high-density lipoprotein (HDL) (r = 0.111, P = 0.053) and a negative correlation to 2-h post-oral glucose-tolerance test (OGTT) was observed (r = -0.202, P = 0.045). In neither group any association was found between telomere length and cholesterol, serum triglycerides, serum low-density lipoprotein, plasma insulin, blood pressure, pulse pressure, or smoking habits. Our data indicate that telomere length is associated with an "obesity-phenotype" but only in women.

Health Risks of Smoking Compared to Swedish Snus

Interest in tobacco harm reduction strategies has raised the question of the comparative health risks of cigarette smoking and use of other tobacco products. Although there appears to be a general belief that a unique smokeless tobacco product called Swedish snus has fewer health risks than cigarettes, no one has systematically reviewed the literature and compared the data on health risks in a quantitative manner. We reviewed the literature to identify all analytic epidemiologic studies that provided quantitative risk estimates associated with Swedish snus and cigarette smoking in a single population, using a common reference group. Seven studies were identified that addressed eight health outcomes. Although few in number, these seven studies do provide quantitative evidence that, for certain health outcomes, the health risks associated with snus are lower than those associated with smoking. Specifically, this is true for lung cancer (based on one study), for oral cancer (based on one study), for gastric cancer (based on one study), for cardiovascular disease (based on three of four studies), and for all-cause mortality (based on one study). This review has likely omitted many of the adverse effects of cigarettes, but probably few of the potential health effects of snus. Continued investigation of the reduced health risks of Swedish snus compared to cigarette smoking is warranted.

Social differences in smoking and snuff use among Norwegian adolescents: a population based survey

BACKGROUND

A change in pattern of tobacco use has been observed in the last decade in Norway. Snuff use and occasional smoking have to some degree replaced daily smoking among adolescents and young adults. Daily smoking is known to be negatively associated with social background factors, but little is known about these associations for other types of tobacco use. Our aim was to study different types of tobacco use among adolescents according to gender, educational ambitions, family background factors, and urbanization.

METHODS

Cross-sectional, school-based study with 15 931 participants and response-rate 87%, conducted among 15 and 16 year olds during 2000-2004.

RESULTS

More girls (33.8%) than boys (26.4%) were daily or occasional smokers, while more boys (21.4%) than girls (3.5%) were daily or occasional snuff users. Daily smoking was more common among adolescents planning vocational education, with single parents or poor family economy. Occasional smoking and snuff use (daily or occasionally) showed a similar, but less pronounced pattern regarding education and single parent families. Adolescents with parents from foreign countries were less likely to use tobacco. One exception was boys with parents from Muslim majority countries who had an increased risk of daily smoking. A typical combination user of both tobacco types was a Norwegian boy with divorced parents and ambitions to complete vocational studies or only one year of upper secondary school.

CONCLUSION

Tobacco use in adolescents is mainly associated with low educational ambitions and less affluent self-reported family economy. Adolescents with divorced parents use more tobacco than those living with both parents. Public health initiatives to avoid or reduce tobacco use should mainly target adolescents in vocational studies and those leaving school early.

Tobacco harm reduction: an alternative cessation strategy for inveterate smokers

According to the Centers for Disease Control and Prevention, about 45 million Americans continue to smoke, even after one of the most intense public health campaigns in history, now over 40 years old. Each year some 438,000 smokers die from smoking-related diseases, including lung and other cancers, cardiovascular disorders and pulmonary diseases. Many smokers are unable--or at least unwilling--to achieve cessation through complete nicotine and tobacco abstinence; they continue smoking despite the very real and obvious adverse health consequences. Conventional smoking cessation policies and programs generally present smokers with two unpleasant alternatives: quit, or die. A third approach to smoking cessation, tobacco harm reduction, involves the use of alternative sources of nicotine, including modern smokeless tobacco products. A substantial body of research, much of it produced over the past decade, establishes the scientific and medical foundation for tobacco harm reduction using smokeless tobacco products. This report provides a description of traditional and modern smokeless tobacco products, and of the prevalence of their use in the United States and Sweden. It reviews the epidemiologic evidence for low health risks associated with smokeless use, both in absolute terms and in comparison to the much higher risks of smoking. The report also describes evidence that smokeless tobacco has served as an effective substitute for cigarettes among Swedish men, who consequently have among the lowest smoking-related mortality rates in the developed world. The report documents the fact that extensive misinformation about ST products is widely available from ostensibly reputable sources, including governmental health agencies and major health organizations. The American Council on Science and Health believes that strong support of tobacco harm reduction is fully consistent with its mission to promote sound science in regulation and in public policy, and to assist consumers in distinguishing real health threats from spurious health claims. As this report documents, there is a strong scientific and medical foundation for tobacco harm reduction, and it shows great potential as a public health strategy to help millions of smokers.

Tobacco use among Swedish schoolchildren

OBJECTIVE

To study the prevalence of snus use and of smoking among Swedish schoolchildren from 1989 to 2003.

DESIGN

Surveys conducted by the Swedish Council for Information on Alcohol and Other Drugs.

SETTING

All of Sweden.

SUBJECTS

84,472 boys and girls age 15-16 years.

MAIN OUTCOME MEASURES

Subjects are classified as non-smokers, occasional smokers, and regular smokers, and into three similar categories for snus use. Tobacco use is reported as sex specific prevalence.

RESULTS

During the period 1989 to 2003, the prevalence of tobacco use declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.

CONCLUSIONS

The high prevalence of snus use in Sweden not only reduces smoking rates among Swedish men, but suppresses smoking among boys as well.