Snuff--how dangerous is it? The controversy continues

Association of smokeless tobacco and cerebrovascular accident: a systematic review and meta-analysis of global data

BACKGROUND

The association of smokeless tobacco (SLT) with stroke has been dealt with in only a few reviews. The present meta-analysis aims to present the updated comprehensive summary risk of stroke in adult SLT users along with sub group analysis.

METHODS

A systematic literature search for articles evaluating risk of stroke in SLT users was conducted. The study characteristics and risk estimates were extracted independently by two authors (RG and SG). Random-effect model was used to estimate the summary relative risks.

RESULTS

The overall risk of stroke in SLT users was found to be significantly higher (1.17, 95% CI 1.04–1.30) compared to non-users, especially for users in Southeast Asian region. The results remained unchanged even after strict adjustment for smoking (1.18, 95% CI 1.04–1.32). SLT users had 1.34 times or 13.4% higher risk of fatal stroke, though risk of nonfatal stroke was not enhanced. Significantly higher risk of stroke was seen in users of chewing tobacco (1.35, 95% CI 1.20–1.50) in comparison to non-chewers. Gender-based analysis showed enhanced risk of fatal stroke in both male and female users. SLT-attributable fraction of fatal stroke was highest for India at 14.8%.

CONCLUSION

The significant higher risk of stroke with SLT use, even after adjustment for smoking, emphasizes the imperative need to include SLT cessation advice for control and prevention of stroke.

Rhinologic signs associated with snuff taking

OBJECTIVE

To study rhinologic signs associated with nasal tobacco (snuff) intake in Parakou, northern Benin.

MATERIALS AND METHODS

A cross-sectional descriptive comparative study included 300 tobacco snuff takers and 300 subjects who did not use tobacco at all. The sampling technique was a stratified 4-stage random sample for non-users and a convenience non-random sample for snuff takers.

RESULTS

The sex-ratio was 0.92 in non-users and 41.9 in snuff takers. Duration of snuff taking was more than 20 years in 24.3% of cases. The symptoms studied were significantly more frequent in snuff takers than non-users (P<0.05). Snoring was reported by 58.3% of snuff takers, versus 5.7% of non-users (P=0.000). Nasal obstruction and rhinorrhea were reported by respectively 26.3% and 22.7% of snuff takers, versus 6.3% and 5.3% of non-users (P=0.000). Hyposmia was reported by 14% of snuff takers, versus 1.3% of non-users (P=0.000). Anterior rhinoscopy found abnormalities in 81.7% of snuff takers, compared to 10.67% of non-users. Nasal hypertrichosis was more frequent in snuff takers than non-users: 40% versus 5% (P=0.000).

CONCLUSION

Nasal intake of tobacco is responsible for morbidity in snuff takers compared to non-users of tobacco.

Effects of maternal smokeless tobacco use on selected pregnancy outcomes in Alaska Native women: a case-control study

OBJECTIVE

To examine the potential effects of prenatal smokeless tobacco use on selected birth outcomes.

DESIGN

A population-based, case-control study using a retrospective medical record review.

POPULATION

Singleton deliveries 1997-2005 to Alaska Native women residing in western Alaska.

METHODS

Hospital discharge codes were used to identify potential case deliveries and a random control sample. Data on tobacco use and confirmation of pregnancy outcomes were abstracted from medical records for 1123 deliveries. Logistic regression was used to examine associations between tobacco use and pregnancy outcomes. Adjusted odds ratios (OR), 95% confidence intervals (95% CI), and p-values were calculated.

MAIN OUTCOMES MEASURES

Preterm delivery, pregnancy-associated hypertension, and placental abruption.

RESULTS

In unadjusted analysis, smokeless tobacco use was not significantly associated with preterm delivery (OR 1.44, 95% CI 0.97-2.15). After adjustment for parity, pre-pregnancy body mass index, and maternal age, the point estimate was attenuated and remained non-significant. No significant associations were observed between smokeless tobacco use and pregnancy-associated hypertension (adjusted OR 0.92, 95% CI 0.56-1.51) or placental abruption (adjusted OR 1.11, 95% CI 0.53-2.33).

CONCLUSIONS

Prenatal smokeless tobacco use does not appear to reduce risk of pregnancy-associated hypertension or to substantially increase risk of abruption. An association between smokeless tobacco and preterm delivery could not be ruled out. Components in tobacco other than nicotine likely play a major role in decreased pre-eclampsia risk in smokers. Nicotine adversely affects fetal neurodevelopment and our results should not be construed to mean that smokeless tobacco use is safe during pregnancy.

Maternal smokeless tobacco use in Alaska Native women and singleton infant birth size

OBJECTIVE

To examine the effects of maternal prenatal smokeless tobacco use on infant birth size.

DESIGN

A retrospective medical record review of 502 randomly selected deliveries.

POPULATION AND SETTING

Singleton deliveries to Alaska Native women residing in a defined geographical region in western Alaska, 1997-2005.

METHODS

A regional medical center's electronic records were used to identify singleton deliveries. Data on maternal tobacco exposure and pregnancy outcomes were abstracted from medical records. Logistic models were used to estimate adjusted mean birthweight, length and head circumference for deliveries to women who used no tobacco (n=121), used smokeless tobacco (n=237) or smoked cigarettes (n=59). Differences in mean birthweight, length and head circumference, 95% confidence intervals and p-values were calculated using non-users as the reference group.

MAIN OUTCOME MEASURES

Infant birthweight, crown-heel length and head circumference.

RESULTS

After adjustment for gestational age and other potential confounders, the mean birthweight of infants of smokeless tobacco users was reduced by 78 g compared with that of infants of non-users (p=0.18) and by 331 g in infants of smokers (p<0.01). No association was found between maternal smokeless tobacco use and infant length or infant head circumference.

CONCLUSIONS

We found a modest but non-significant reduction in the birthweight of infants of smokeless tobacco users compared with infants of tobacco non-users. Because smokeless tobacco contains many toxic compounds that could affect other pregnancy outcomes, results of this study should not be construed to mean that smokeless tobacco use is safe during pregnancy.

Patterns of cigarette and smokeless tobacco use before, during, and after pregnancy among Alaska native and white women in Alaska, 2000-2003

OBJECTIVE

To examine patterns of cigarette and smokeless tobacco use before, during, and after pregnancy among Alaska Native (AN) and white women living in Alaska.

METHODS

We used data from the 2000-2003 population-based Pregnancy Risk Assessment Monitoring System to describe patterns of self-reported prenatal tobacco use among AN and white women. We used multiple variable logistic regression analysis to identify maternal factors associated with quitting and relapse. The final sample included 5,458 women.

RESULTS

During 2000-2003, the prevalence of any tobacco use before pregnancy was twofold higher among AN women than among white women (60.0 vs. 27.5%), and the prevalence of any tobacco use during pregnancy and after pregnancy were each nearly threefold higher. Of the 25.8% (SE 0.9) of white women who smoked before pregnancy, 49.0% (SE 2.1) reported that they quit during pregnancy and of those, 41.1% (SE 2.9) relapsed postpartum. Of the 38.5% (SE 0.9) of AN women who smoked before pregnancy, 35.7% (SE 1.4) quit, and of those 57.0% (SE 2.4) relapsed. Of the 14.2% of AN women who chewed tobacco before pregnancy, 15.7% (SE 1.7) quit, and of those, 52.9% (SE 5.9) relapsed.

CONCLUSION

During 2000-2003, the prevalence of tobacco use was two to three times higher among AN women than among white women before, during, and after pregnancy. In addition, AN women had lower quit rates and higher relapse rates than white women. Comprehensive, culturally appropriate tobacco control approaches targeting AN women are needed to increase cessation during pregnancy and to decrease relapse.

Prenatal cigarette smoking and smokeless tobacco use among Alaska native and white women in Alaska, 1996-2003

OBJECTIVE

To examine trends in prenatal cigarette smoking and smokeless tobacco use among Alaska Native (AN) and white women in Alaska.

METHODS

Using 1996-2003 data from the population-based Pregnancy Risk Assessment Monitoring System, we determined trends in self-reported prenatal tobacco use among AN and white women and used chi-square tests and multiple variable logistic regression analysis to identify maternal factors associated with prenatal tobacco use.

RESULTS

Over the study period, prevalence of any tobacco use during pregnancy declined by 27% among AN women (from 55.8 to 40.9%) (P < 0.0001) and by 17% among white women (from 18.8 to 15.6%) (P < 0.0001). In 2003, among AN women the prevalence of self-reported smokeless tobacco use was 16.9%, cigarette smoking was 25.7%, and any tobacco use was 40.9%; corresponding values for white women were 0.4, 15.0, and 15.6%, respectively. Western Alaska had the highest prevalence of tobacco use.

CONCLUSION

The prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women than white women, especially for smokeless tobacco. Support for cessation interventions targeting pregnant women should be made a public health priority in Alaska.

Marital life course events and smoking behaviour in Sweden 1980–2000

The protective effect of marriage on smoking has been extensively established in the literature. However, less is known about the dynamics of how smoking behaviour is connected to various marital life course events, and whether there are any gender discrepancies in this respect. In this article the connection between the marital life course and smoking is analysed from a stress-related perspective controlling for other socio-economic characteristics. We use information on 81,000 individuals from the Swedish longitudinal micro-level ULF (Survey of Living Conditions) database 1980-2000, which is randomly drawn from the sample population of all Swedes aged 16-84. Logistic regressions on current smoking status and changes in smoking behaviour of participants in the panel part of the data are estimated. The marital life course is strongly linked to smoking behaviour with being or getting married indicating low smoking risks and marital disruption indicating high risks. The divorced smoke to a higher extent than the widowed and there are signs that getting divorced implies higher risks than becoming widowed, both of taking up/relapsing and, for women, not being able to quit. Further, the results indicate that the connection between smoking cessation and living with a partner is stronger for men, whereas women are more affected by the propensity to start smoking after marital disruption. The protective effect of being married on smoking decreases with the age difference between spouses in households where the wife is older than the husband. Taken together, the results yield a rather complex pattern of smoking behaviour over the marital life course. Further, perceived financial stress is strongly connected to smoking and not being able to quit. Controlling for this effect still leaves a socio-economic status gradient in smoking.

Steady‐state nicotine plasma levels following use of four different types of Swedish snus compared with 2‐mg Nicorette chewing gum: A crossover study

The present study evaluated nicotine plasma levels achieved following 1 day's regular use of four commonly used brands of Swedish portion snus and 2-mg Nicorette chewing gum. The study also estimated the amount of sodium chloride extracted from each snus sachet to identify potential risks for exacerbation of heart failure and hypertension with the use of Swedish snus. Extracted dose of nicotine, area under the venous plasma concentration-time curve (AUC), maximum plasma nicotine concentration (Cmax) of the last (12th) dosing interval, and the Cmax and AUC ratios versus Nicorette were calculated. Relative bioavailable dose was calculated using AUC of 2-mg Nicorette gum as the reference. The mean extracted nicotine doses were 2.74+/-0.80, 1.55+/-0.68, 2.00+/-0.56, and 1.08+/-0.94 mg/sachet for General, Catch Licorice, Catch Mini, and Catch Dry Mini snus, respectively. The approximate bioavailable dose of nicotine from snus was 40%-60% of the extracted dose. The steady-state nicotine plasma concentration-time curve for the weakest brand, Catch Dry Mini portion snus, did not differ significantly from that of the 2-mg Nicorette gum. The AUC and Cmax for Catch Licorice 1 g and Catch Mini 0.5 g portion snus were twice those for the 2-mg Nicorette gum; for the strongest brand, General, these values were 2(1/2) times those for Nicorette gum. The differences in AUC and Cmax versus the 2-mg Nicorette gum were statistically significant (p=.020). Nicotine plasma levels with General portion snus were sustained at higher levels than current nicotine replacement therapy products, peaking at 29.0+/-8.5 ng/ml, and more closely mimicking cigarette smokers' nicotine plasma levels. The risks of aggravation of heart failure and hypertension with respect to increased salt load from the use of snus appeared to be negligible.

Adverse pregnancy outcomes in snuff users

OBJECTIVE

The purpose of the study was to evaluate the effects of smokeless tobacco use during pregnancy.

STUDY DESIGN

We examined birth weight, preterm delivery, and preeclampsia in women who were delivered of singleton, live-born infants in Sweden from 1999 through 2000. For each snuff user, 10 cigarette smokers and 10 tobacco nonusers were selected randomly.

RESULTS

After exclusions, 789 snuff users, 11,240 smokers, and 11,495 nonusers remained. Compared with nonusers, adjusted mean birth weight was reduced in snuff users by 39 g (95% CI, 6-72 g) and in smokers by 190 g (95% CI, 178-202 g). Preterm delivery was increased in snuff users and smokers (adjusted odds ratios, 1.98 [95% CI, 1.46-2.68] and 1.57 [95% CI, 1.38-1.80], respectively). Preeclampsia was reduced in smokers (adjusted odds ratio, 0.63; 95% CI, 0.53-0.75) but increased in snuff users (adjusted odds ratio, 1.58; 95% CI, 1.09-2.27).

CONCLUSION

Snuff use was associated with increased risk of preterm delivery and preeclampsia. Snuff does not appear to be a safe alternative to cigarettes during pregnancy.

Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control study

BACKGROUND AND PURPOSE

Snuff and other forms of smokeless tobacco are widely used in some populations. Whereas the detrimental cardiovascular effects of smoking are well documented, possible health hazards associated with the use of smokeless tobacco remain controversial. The purpose of this study was to explore whether the use of snuff, a smokeless tobacco product, increases the risk of stroke in men.

METHODS

In a nested case-control study (1 case and 2 matched controls without cardiovascular disease), information on tobacco habits was collected through population risk factor surveys. During follow-up, first-ever fatal and nonfatal strokes occurring among 25- to 74-year-old participants were identified in a population-based stroke register. The study was restricted to men (276 cases, 551 controls).

RESULTS

The unadjusted odds ratio for stroke in regular cigarette smokers compared with men who never used tobacco was 2.21 (95% CI, 1.29 to 3.79). When never-smoking regular snuff dippers (excluding ex-smokers) were compared with men who never used tobacco, the unadjusted odds ratio was 1.05 (95% CI, 0.37 to 2.94). The odds ratio for never-snuffing smokers versus never-smoking snuff users was 2.90 (95% CI, 0.92 to 9.1). After adjustment for multiple cardiovascular risk factors, the odds ratio for having a stroke was 1.74 (95% CI, 0.85 to 3.54) in regular smokers and 0.87 (95% CI, 0.41 to 1.83) in regular snuff users.

CONCLUSIONS

Whereas regular smoking doubles the risk of stroke in men, snuff use is not associated with any apparent excess risk. Chemical moieties produced by burning tobacco are probably the most important contributors to smokers' excess risk of atherothrombotic disease, including stroke.

Evolving patterns of tobacco use in northern Sweden

BACKGROUND AND OBJECTIVES

Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999.

DESIGN

This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999.

RESULTS

Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05).

CONCLUSIONS

The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.

Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature

OBJECTIVE AND IMPORTANCE

Isolated fungal granulomas originating within the sphenoid sinus are extremely rare in immunocompetent patients. In their symptoms and morphological appearance, these lesions may be mistaken for pituitary tumors. We report such a case and review the literature.

CLINICAL PRESENTATION

A 74-year-old man presented with a 3-week history of Cranial Nerve III paresis. The patient had a long-term history of snuff abuse. Computed tomography demonstrated a space-occupying lesion of the sellar and sphenoid sinus region with displacement of the cavernous sinus.

INTERVENTION

The lesion was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, mucus extruded spontaneously, and a brownish, crumbly mass was found and removed. The lesion had completely eroded the sella and clivus. Histological analysis revealed numerous Aspergillus hyphae. Postoperatively, the IIIrd cranial nerve paresis resolved completely within a few days. No systemic fungal infection was found in extensive serological studies. There was no evidence of immunosuppression.

CONCLUSION

Fungal granuloma must be included in the differential diagnosis of lesions in the sellar region, even in nonimmunosuppressed patients. Early diagnosis and transsphenoidal extirpation is crucial with this potentially life-threatening disease.