Smokeless tobacco use in Sweden and other 17 European countries

Effects of Smokeless Tobacco Use on the Upper Gastrointestinal Tract Mucosa: Gross and Histopathological Changes

BACKGROUND/AIM

Tobacco addiction is prevalent in South and Southeast Asia. This study aimed to assess upper gastrointestinal (GI) tract changes in smokeless tobacco (SLT) users through upper GI endoscopy (UGIE).

MATERIALS AND METHODS

A cross-sectional observational study, including 108 SLT users and 90 controls who did not use tobacco, was conducted at an Indian tertiary care hospital from March 2022 to February 2023. Participants were categorized into three groups: Non-SLT users (Group A), SLT users for <10 years (Group B), and SLT users for >10 years (Group C). UGIE and biopsies from the lower esophagus, stomach, and duodenum were performed, noting gross and pathological findings.

RESULTS

There were 89 males and 19 females. More than 60% of patients used SLT for more than 10 years. Grossly, erosive and ulcerative lesions of the esophagus and stomach were the most common findings. Barrett's esophagus (14/108 patients) and esophageal neoplasms (5/108 patients) were found in 19/108 patients (17.59%). Common biopsy findings were chronic gastritis and duodenitis. Group C had a significantly high finding of gastric ulcers compared to other 2 groups. A total of 68/108 SLT users (62.96%) had Helicobacter pylori infection which was significantly higher compared to the controls ( P < 0.05).

CONCLUSION

Chronic SLT use was found to be associated with gross and histological changes in the upper GI tract such as chronic erosions, peptic ulcers, and neoplastic growths. UGIE must be done routinely in all these patients whenever they develop chronic dyspepsia for early diagnosis and management.

Oral Cancer Incidence Among Adult Males With Current or Former Use of Cigarettes or Smokeless Tobacco: Population-Based Study

Background

Tobacco use has been identified as a risk factor for oral cancer worldwide. However, relative oral cancer incidence among adults who smoke cigarettes, use smokeless tobacco products (ST), have transitioned from cigarettes to ST, quit cigarettes and/or ST ("quitters"), or never used tobacco has not been well studied.

Objective

We aim to present population-based oral cancer incidence rates for adults who smoke cigarettes, use ST, are former smokers who now use ST, or quit.

Methods

We estimated cross-sectional incidence rates and incidence rate ratios (IRRs) using data from statewide cancer registries (Colorado, Florida, North Carolina, and Texas) and population counts derived from national surveys using combined data from 2014-2017. A random-effect meta-analysis approach was used to summarize estimates among these groups, based on multiple imputation-based IRR estimates by state and age group while considering potential heterogeneity.

Results

A total of 19,536 oral cancer cases were identified among adult males 35 years and older in the study geographies and period. The oral cancer incidence rate among adults who smoke was significantly higher than the ST group (2.6 times higher, 95% CI 2.0-3.3, P<.001), 3.6 (95% CI 3.2-4.1, P<.001) times higher than the never users, and 2.4 (95% CI 1.8-3.1, P<.001) times higher compared to former smokers who now use ST. The IRR among the ST group relative to never users was 1.4 (95% CI 1.1-1.9, P=.02). The IRR between former smokers who now use ST and those who quit was 1.4 (95% CI 1.0-2.1, P=.08).

Conclusions

Findings from this population-based study with a large number of oral cancer cases support significantly high oral cancer incidence among adults who smoke and a lower risk of oral cancer incidence among never users, quitters, users of ST, and former smokers who now use ST compared to cigarettes. Future studies with detailed control of tobacco history and other relevant confounders are needed to confirm these findings.

Effects of exposure to snus marketing with versus without modified risk tobacco product claims on snus use intention and perceived harm among young adults

BACKGROUND

We tested whether snus marketing with modified risk tobacco product (MRTP) claims: (a) promotes accurate knowledge about snus's health effects in young adults and (b) encourages use intentions in only those who use combustible tobacco without attracting other young adult populations.

METHODS

A randomised between-subjects experiment was embedded in a 2020 web survey of participants from Los Angeles (aged 19-23 years). Participants viewed mass-marketed snus advertising materials with (n=1212) vs without (n=1225) US Food and Drug Administration-authorised MRTP claims. After advertising exposure, snus use intention and perceptions of snus harms relative to cigarettes or e-cigarettes were measured.

RESULTS

Advertisements with versus without MRTP claims did not affect snus use intention (18.0% vs 19.4%) but produced a higher prevalence of perceptions that snus was less harmful than cigarettes (12.6% vs 9.1%; p=0.007) and e-cigarettes (8.0% vs 5.8%; p=0.04). MRTP claim exposure effects did not differ by past 30-day e-cigarette or combustible tobacco use. Snus use intentions after marketing exposure, collapsed across MRTP claim conditions, were higher in those who did versus did not report past 30-day use of e-cigarettes (38.4% vs 14.3%; adjusted OR (95% CI) 2.95 (2.28 to 3.81); p<0.001) or combustible tobacco (44.0% vs 16.2%; adjusted OR (95% CI) 2.26 (1.62 to 3.16); p<0.001).

CONCLUSION

Although some young adults who vape or smoke may have snus use intentions, snus MRTP claims might not affect young adults' snus use intentions, regardless of whether they vape/smoke. MRTP claims might modestly increase the accuracy of perceived harms of snus relative to cigarettes while also slightly causing unsubstantiated perceptions of lower harm than e-cigarettes.

The Effects of Nicotine Pouches and E-Cigarettes on Oral Microbes: A Pilot Study

It remains uncertain whether nicotine pouches and electronic cigarettes alter the oral environment and result in a high presence of periodontopathogenic bacteria in saliva, compared to that among cigarette users or non-tobacco users. In this study, saliva samples were collected from respondents using nicotine pouches, electronic cigarettes, and conventional cigarettes, alongside a control group of non-tobacco users. Polymerase chain reaction was used to identify clinical isolates of the following periodontal bacteria: Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, Fusobacterium nucleatum, Fusobacterium periodonticum, Porphyromonas endodontalis, and Rothia mucilaginosa. The presence of some periodontal pathogens was detected in the saliva samples from users of nicotine pouches, electronic cigarettes, and conventional cigarettes but not in samples taken from the control group. Therefore, the initial results of this pilot study suggest that the presence of periodontopathogenic bacteria in the saliva of nicotine pouch and electronic cigarette users could alter the oral microbiome, leading to periodontal diseases. However, further quantitative investigation is needed.

Snus Use in Adolescents: A Threat to Oral Health

Background: Snus consumption is increasingly popular, mainly among the youth, due to the promotion of the tobacco industry and the lack of knowledge regarding its adverse effects. Even though some of its systemic complications are common knowledge, the oral consequences are rarely known. Aim: Therefore, the objective of this study is to evaluate the oral health effects of snus consumption among a highly exposed group of adolescent athletes. Design: Participants received an interactive presentation, followed by interviews and dental screenings by young doctors to establish trust. They were categorized into groups based on the frequency of snus usage. The oral hygiene habits and status, snus consumption habits, and awareness about its adverse effects were evaluated. Results: Statistically significantly (p < 0.05), more regular snus users experience gum bleeding while tooth brushing than nonusers (60% and 37%, p = 0.004). Snus consumption and poor oral hygiene have a cumulative effect on oral health. Some young athletes experience ulcerous oral mucosal lesions coinciding with snus placement. Nonusers exhibit greater awareness of the adverse effects of snus than regular users (27% and 49%). Conclusions: Regular snus use negatively affects oral health, especially the gums. Early education is of the utmost importance in preventing snus usage by raising awareness.

First experience with nicotine products and transition to regular tobacco use: a secondary data analysis in 28 European countries

OBJECTIVE

The majority of tobacco users have had their first contact with nicotine at a young age. The aim of this study was to explore the association between the first tobacco or nicotine product tried and the transition to regular product use in 28 European countries.

METHODS

A secondary analysis of participants aged 15-40 years (n=8884) from 28 countries was conducted (Eurobarometer wave 93.2; August-September 2020). Participants who reported having ever tried tobacco or nicotine products were asked which product they tried first. Self-reported history of tobacco use determined whether they were established users (≥1 time weekly) of a range of products at any point in their life. Multilevel logistic regression was used to measure the association between first product tried and becoming a regular user of tobacco or nicotine products.

RESULTS

There was large variation between countries in the proportion of participants aged ≤40 years that ever tried tobacco or nicotine; Estonia had the highest proportion of ever users (85.8%) and Poland had the lowest (38.9%). Among those who had ever tried tobacco or nicotine, boxed cigarettes were the most common first product (72.3%) and pipe was the least common (0.4%). Compared with those who first tried e-cigarettes, the odds of ever becoming a regular user of any tobacco or nicotine product were higher among those who first had hand-rolled cigarettes (adjusted OR, aOR 2.23; 95% CI 1.43 to 3.48) or boxed cigarettes (aOR 2.08; 95% CI1.43 to 3.02) and lower among those who first tried waterpipe (aOR 0.22; 95% CI 0.14 to 0.34).

CONCLUSIONS

Although this study cannot infer causality, the findings show that odds of becoming a regular tobacco user differs widely depending on the first product used. Better understanding of the associations between first product use and regular tobacco use could be informative to tobacco control policy-makers and help tailor prevention programmes.

Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty

BACKGROUND

Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. It is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus patients who smoke.

METHODS

A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Joint complication rates within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions.

RESULTS

Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls.

CONCLUSION

Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective THA. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative counseling.

Oral lichenoid lesions in two snuff users with contact allergy to carvone

BACKGROUND

Contact allergy to the mint-tasting flavour carvone has been observed in patients with oral lichenoid lesions (OLL). Mint-flavoured products such as toothpaste frequently contain carvone. Snuff is a smokeless tobacco product that is chewed or placed in the mouth rather than smoked. In Sweden, the use of snuff and its flavoured versions is extremely common.

OBJECTIVES

To investigate whether the consumption of mint-flavoured snuff is associated with contact allergy to carvone and subsequently plays a role in the aetiology of OLL.

METHODS

Regarding the two patients, patch testing with snuff pouches was performed. High-performance liquid chromatography and gas chromatography-mass spectrometry analysis were used for identification of carvone in different snuff samples.

RESULTS

Two patients with OLL were contacted allergic to carvone when patch tested. Both were using mint-flavoured snuffs several hours a day for many years. One patient was contacted allergic to the snuff pouch tested as is. Carvone was detected in the snuff samples of both patients.

CONCLUSIONS

The patients were recommended to avoid the use of mint-flavoured snuffs, toothpaste and foodstuffs. At follow-up 3 months later, the patients had a dramatic clinical improvement of the OLL and oral symptoms. Exposure to mint-flavoured snuffs can be overlooked as a possible aggravating/provoking factor in OLL.

The Association Between Tobacco Use and Risk of COVID-19 Infection and Clinical Outcomes in Sweden: A Population-Based Study

Background: The association between tobacco use and COVID-19 is controversial. During the early course of the pandemic, limited testing prevented studying a wide spectrum of clinical manifestations. Objective: To examine the potential causal association between tobacco use and COVID-19 during the second wave (1 October 2020-30 June 2021) of the pandemic in Stockholm, Sweden. Methods: A population-based cohort study was conducted in the Stockholm region of Sweden, with information on tobacco use collected prior to the pandemic. Adjusted relative risks (RR) of COVID-19 and 95% confidence intervals (CI) were calculated, contrasting current smokers and snus users to non-users of tobacco. Results: Compared with non-users of tobacco, current smokers had a lower risk of COVID-19 (RR 0.78, 95% CI = 0.75-0.81) and of hospitalisation for the disease. Current snus users had a higher risk of COVID-19. Heavy smokers and snus users had longer hospital stays than non-users of tobacco. Conclusion: Tobacco use may have a different impact on the risk of being infected with SARS-CoV-2 and the risk of developing severe clinical manifestations. Further research is needed to determine the underlying mechanisms.

Pan-American prevalence of smokeless tobacco use and association with oral potentially malignant disorders and head and neck cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of smokeless tobacco (SLT) use and its association with oral potentially malignant disorders (OPMDs) and head and neck cancer (HNC) in the Pan-American Health Organization (PAHO) region.

STUDY DESIGN

A literature search was conducted across 9 databases and other sources. The eligibility criteria were pediatric (0-18 years old) and adult (19 years and older) populations consuming any type of SLT. Meta-analysis was performed to determine the prevalence of SLT and the association between its use and OPMDs/HNC in the PAHO region; the Grading of Recommendations Assessment, Development, and Evaluation tool was used to verify the certainty of evidence.

RESULTS

Fifty-nine studies from 6 PAHO countries were included, of which 51 were also subjected to quantitative analysis. The pooled SLT prevalence of use was 15% (95%CI: 11.93-18.69) overall, 17% (95%CI: 13.25-22.65) in adults, and 11% (95%CI: 8.54-14.78) in the pediatric population. The highest reported SLT prevalence of use was 33.4% (95%CI: 27.17-39.93) in Venezuela. HNC was positively associated with SLT use (OR = 1.98, 95%CI: 1.54-2.55), with a moderate certainty of evidence. Among OPMDs, only leukoplakia reported a positive association with SLT use (OR = 8.38; 95%CI: 1.05-67.25). However, the quality of the evidence was very low.

CONCLUSION

A high consumption of SLT use, chewing tobacco and snuff, is reported among the adult population residing in the PAHO region with a positive association with the development of oral leukoplakia and HNC.

'No-Barriers' tobacco product? Selling smokeless tobacco to women, people of colour and the LGBTQ+ community in the USA

BACKGROUND

In both Sweden and the USA, smokeless tobacco (ST) is legal and used predominantly by men. Starting in the 1970s, US tobacco companies attempted to expand the ST market to women, African Americans, Hispanic Americans and lesbian, gay, bisexual, transgender, queer and other sexual orientation (LGBTQ+) people.

DESIGN

We analysed industry documents from the Truth Tobacco Industry Documents Library triangulating findings with recent ST advertising and publicly available literature.

FINDINGS

We found tobacco companies used design innovations such as pouched moist snuff, snus and dissolvable products to expand the market. In addition, diverse advertising campaigns targeted women, people of colour (Hispanic, African American) and LGBTQ+ communities with identity-targeted messages emphasising novelty, convenience, cleanliness and use in smoke-free environments. However, stereotypes of ST users as rural white males endured, perpetuated by continued marketing aimed at this customer base, which created cognitive dissonance and stymied marketer's hopes that pouch products would 'democratize' ST.

CONCLUSION

These failed campaigns suggest novel products such as nicotine pouch products may provide a 'clean slate' to similarly target women and other low-ST-using groups. Based on this history, the risk of new tobacco and nicotine products to increase health disparities should be closely monitored.

Trends in Tobacco Use among 9th Graders in Sweden, 1991-2020

Tobacco use was measured with self-reports of lifetime use of cigarettes and snus to examine trends in tobacco use among Swedish 9th graders over the period 1991-2020. Annual school surveys with nationally representative samples of 9th-grade students in Sweden covering the period 1991-2020 with a total sample of 163,617 students. We distinguished between the use of cigarettes only, use of snus only, dual use (use of both cigarettes and snus), and total tobacco use (use of any of these tobacco products). In addition to a graphical description of trends in the various measures of tobacco use, the correlation between these trends was calculated with the Pearson correlation coefficient (Rxy). The prevalence of total tobacco use declined from 72% in 1991 to 36% in 2020. The declining trend in total tobacco use was positively correlated with the trend in dual use (Rxy = 0.98) and the trend in cigarette use only (Rxy = 0.87). The trend in total tobacco use was, on the other hand, negatively correlated with snus use only (Rxy = -0.41), and snus use only was negatively correlated with cigarette use only (Rxy = -0.71). The situation became different after 2017 when total tobacco use increased as a result of an increasing prevalence of snus use. The sharp decline in tobacco use among 9th graders in Sweden over the past three decades is driven by declining cigarette use. The correlations between the various forms of tobacco use suggest that snus use may have contributed to the decline in cigarette use and, by that, overall tobacco use. The situation changed after 2017 when a sharp rise in snus use seems to have increased total tobacco use among adolescents in Sweden. A possible explanation behind this development is the introduction of a new form of snus called "All white snus", which was introduced in Sweden in 2014.

Factors associated with initiation and use of snus among adolescents

AIM

We investigated factors associated with the initiation and continuation of snus use in adolescents in Norway. The associations with adolescents' own educational plans, the parents' educational level(s) and tobacco habits were estimated.

METHODS

In this cross-sectional questionnaire-based study, 1465 patients aged 18-20 years participated. The questionnaire was administered at regular dental examinations in the public dental health service. To assess the association between individual factors and the initiation of tobacco habits, a generalised structural equation model with random effects at the clinic level was used. Binary responses were modelled using multilevel binary logistic regression, while the number of snus boxes used per month was modelled using a multilevel Poisson regression model.

RESULTS

Of current (daily and occasional) tobacco users, 85% were snus users, including dual users of both snus and cigarettes. The median age of snus initiation was 16 years. Both parental snus use and smoking were associated with an increased risk of snus initiation, snus use and a higher amount of use. An increased risk of using snus was associated with male gender and with no educational plans or planning for further vocational education. The amount of snus used was higher among current snus users with a prior smoking history and among those planning for further vocational education.

CONCLUSIONS

These findings may aid in developing and targeting tobacco prevention strategies aimed at young people. Tobacco prevention measures should start at the elementary school level. The strong association with parental tobacco habits underlines the importance of parents' influence on their children's tobacco use.

Smokeless Tobacco Use is Associated With Worse Outcomes Following Total Knee Arthroplasty

BACKGROUND

Studies have demonstrated increased complication risk after total knee arthroplasty (TKA) in patients who smoke cigarettes, but it is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after TKA in smokeless tobacco users and smokers as compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus smokers to determine if one is associated with significantly higher rates of postoperative complications.

METHODS

A retrospective cohort study was conducted using a national database. For patients who underwent primary TKA, smokeless tobacco users (n = 1,535) and smokers (n = 28,953) were matched at a 1:4 with controls (n = 6,140 and 115,812, respectively), and smokeless tobacco users (n = 1,481) were matched at a 1:4 with smokers (n = 5,924). Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions.

RESULTS

After primary TKA, compared to controls, smokeless tobacco users demonstrated significantly higher rates of aseptic loosening/mechanical failure within 2 years, longer lengths of stay, and higher rates of urinary tract infection, pneumonia, deep vein thrombosis, and acute kidney injury within 90 days. Compared to smokers, smokeless tobacco users demonstrated significantly lower rates of aseptic revision and lower rates of wound disruption.

CONCLUSION

Smokeless tobacco use is associated with higher rates of both medical and joint complications following primary TKA. However, smoking is associated with higher risk for complications than smokeless tobacco use.

LEVEL OF EVIDENCE

Level III.

Nicotine Pouch: Awareness, Beliefs, Use, and Susceptibility among Current Tobacco Users in the United States, 2021

Little is known about awareness, beliefs, and use of nicotine pouches (NPs). Data from 1583 U.S. adult (age ≥ 21 years) current tobacco users were collected in 2021. Respondents self-reported NP awareness, beliefs, use, and susceptibility as well as current tobacco product use and socio-demographics. We used weighted logistic and multinomial regression models to explore the associations between these variables. Overall, 46.6% of U.S. adult current tobacco users were aware of, 16.4% had ever used, and 3.0% currently used NPs. Younger individuals (vs. 61+ years) were more likely to have ever heard of NPs, while Black individuals (vs. White) were less likely to have ever heard of NPs. Individuals younger than 45 years (vs. 61+ years) and those using smokeless tobacco products (vs. non-users) were more likely to have ever used NPs. Additionally, younger than 45 years (vs. 61+ years) and current use of certain tobacco products (e.g., smokeless) were associated with current NP use. Holding favorable beliefs about NPs was associated with susceptibility to and more advanced NP use statuses (p < 0.05). Continuous surveillance of NP use and beliefs is important.

Exploring the perceived sociocultural factors in the initiation of smokeless tobacco among adolescents: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to identify and explore the perceived sociocultural factors leading to smokeless tobacco initiation among the adolescent population.

INTRODUCTION

Smokeless tobacco use is associated with oral cancer and premalignant lesions. The initiation of smokeless tobacco often occurs in adolescence, with multiple sociocultural factors facilitating the commencement of this habit. An in-depth understanding of the factors influencing smokeless tobacco uptake can assist policymakers and tobacco-control units in establishing global policies and implementing control strategies to prevent adolescents' taking up smokeless tobacco.

INCLUSION CRITERIA

This review will consider qualitative studies conducted within the last 20 years on adolescent smokeless tobacco users, focusing on sociocultural factors influencing smokeless tobacco initiation. Studies involving cigarette smoking, other alternative forms of smoking, and any form of tobacco cessation intervention will be excluded.

METHODS

A systematic search will be conducted in MEDLINE, Scopus, CINAHL, Embase, PsycINFO, and the Cochrane CENTRAL databases, using a 3-step search process. ProQuest Dissertations and Theses, OAIster, and Google will be searched for unpublished studies. Only studies published from January 2002 until the present and in English will be considered. Study screening, extraction, and critical appraisal will be performed by 2 independent reviewers using the standardized JBI qualitative appraisal and data extraction tools. Data synthesis will involve aggregation of the review findings to generate a set of statements based on similarity of meaning.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021240588.

Tobacco chewing and associated factors among a vulnerable youth population in Sri Lanka

BACKGROUND

Tobacco in any form kills millions of people every year. Tobacco addiction among youth shows an increasing trend while smokeless type is becoming more common. This study aimed to describe the lifestyle of chewing smokeless tobacco among a group of high-risk youth population in Sri Lanka.

METHODS

A descriptive cross-sectional study was conducted among a sample of 1431 youths aged between 15 to 24 years residing in urban slums in Colombo Sri Lanka, using a cluster sampling technique combined with probability proportionate to size technique. Data were collected using an interviewer-administered questionnaire. Chewing smokeless tobacco was assessed using betel quid chewing and commercially prepared tobacco and areca nut packet chewing. Current chewer was defined as who had the practice of chewing during past 30 days.

RESULTS

The mean age of the study sample was 17.53 (95% CI: 17.40-17.65). Of the 1431 respondents, 57% were males and 43% were females. The prevalence of current smokeless tobacco chewers was 44.9% and among them 90.8% were males and 9.8% were females. Around 31.3% did not have smokeless tobacco chewing practice (Male-5.9%, Female-64.9%). Among the current smokeless tobacco chewers 21.5% chew both types of smokeless tobacco products and all of them were males. Male gender (OR 17.9; 11.4 -27.9) and ever smoking lifestyle (OR 4.4; 2.9-6.6) were significant determinants of current smokeless tobacco chewing lifestyle.

CONCLUSION AND RECOMMENDATIONS

The study shows a high prevalence of smokeless tobacco use by youth aged between 15 to 24 years who were residing in urban slum areas in the district of Colombo, in Sri Lanka, highlighting this target group for early intervention to reduce the uptake and promote the quitting of this practice.

Oral Cancer Risk Assessment for Different Types of Smokeless Tobacco Products Sold Worldwide: A Review of Reviews and Meta-analyses

Smokeless tobacco (SLT) use is a significant cause of lip and oral cavity cancers. Globally, oral cancer prevalence is strongly linked to the types of tobacco products used, their chemical composition, and their pattern of use. Except snus, all SLT products sold in different World Health Organization regions are strongly associated with oral cancer incidence. Shammah showed the highest association OR with 95% confidence intervals (CI; OR, 38.74; 95% CI, 19.50-76.96), followed by oral snuff (OR, 11.80; 95% CI, 8.45-16.49), gutkha (OR, 8.67; 95% CI, 3.59-20.93), tobacco with betel quid (OR, 7.74; 95% CI, 5.38-11.13), toombak (OR, 4.72; 95% CI, 2.88-7.73), and unspecified chewing tobacco (OR, 4.72; 95% CI, 3.13-7.11). Most SLT products containing high levels of carcinogenic tobacco-specific nitrosamines (TSNA) exhibit a high risk of oral cancer. There is an urgent need to frame and implement international policies for oral cancer prevention through legal control of the TSNA levels in all SLT product types.

PREVENTION RELEVANCE

Most smokeless tobacco products sold worldwide, mainly shammah, toombak, gutkha, betel quid with tobacco, and dry snuff, are associated with a high risk of oral cancer. A high concentration of tobacco-specific nitrosamines in smokeless tobacco products is the major causative factor for oral cancer development.

Composition and Ecological Functionality of Fungal Communities Associated with Smokeless Tobacco Products Mainly Consumed in India

The microbial communities present in smokeless tobacco products (STPs) perform critical steps in the synthesis of carcinogens, mainly tobacco-specific nitrosamines (TSNAs). Most studies emphasize the bacterial component, and the mycobiome of STPs has not been well characterized. In this study, we investigated the fungal communities in the different categories of STPs by sequencing the internal transcribed spacer (ITS) rRNA region of the fungal genome. The ecological character of the fungal community associated with STPs was determined by using FUNGuild. Our results indicated that Ascomycota and Basidiomycota were the most abundant fungal phyla across all STPs. The predominant fungal genera in STPs were Pichia, Sterigmatomyces, and Mortierella. The α-diversity varied significantly across the STPs based on observed, Fisher, and Shannon indices. Using SparCC cooccurrence network analysis, significant positive correlations of 58.5% and negative connections of 41.5% were obtained among fungal genera identified in STPs. Furthermore, the functional predictions by FUNGuild determined that STPs possessed high abundances of saprotroph and pathotroph-saprotroph-symbiotroph fungal trophic groups. At the functional guild level, the qiwam samples contained high abundances of soil saprotrophs, while plant pathogens were prevalent in pan-masala samples. These results suggest that various fungal populations reside in STPs and interrelate with each other and can contribute to the synthesis of TSNAs. This study has established the basis for future large-scale investigations of STP-associated mycobiota and the impact of such mycobiota in oral carcinogenesis in STP users via inflammation and carcinogens (TSNAs and mycotoxins). IMPORTANCE Smokeless tobacco products (STPs) contain complex microbial communities that influence the synthesis of carcinogens, such as tobacco-specific nitrosamines (TSNAs). Research on STP-associated bacterial populations revealed connections between bacterial metabolism and TSNA synthesis. The abundance of the fungal population may also have an impact on the production of TSNAs. This study examined STPs popularly used in India, and diverse fungal communities were identified in these STPs. Pichia, Sterigmatomyces, and Mortierella were the predominant fungal genera in the STPs. High abundances of saprotroph and pathotroph-saprotroph-symbiotroph trophic groups in STPs could affect the degradation of tobacco products and the synthesis of TSNAs.

Establishing the Association Between Snus Use and Mental Health Problems: A Study of Norwegian College and University Students

INTRODUCTION

Smoking and mental health problems are public health concerns worldwide. Studies on smoke-free tobacco products, especially snus are scarce. Snus is considered less harmful than smoking and in the United States allowed to be marketed accordingly, but may still add to the burden of disease.

AIMS AND METHODS

Data stem from the Norwegian Students' Health and Wellbeing Study (SHoT study) in 2018 (162 512 invited, 50 054 (30.8%) completed). Smoking, snus use, health service and medication usage and mental health problems, including the Hopkins Symptom Checklist-25 (HSCL-25), were assessed using self-report. The aims were to explore the associations between smoking and snus use and mental health problems and treatments. Furthermore, the association between both daily smoking and daily snus use and mental health problems. Associations were tested with χ2-, t-tests, and logistic regression.

RESULTS

Daily snus users had 38% increased odds (odds ratio [OR]: 1.38, CI: 1.30 to 1.46), and daily smokers had 96% increased odds (OR: 1.96, CI: 1.65 to 2.34) of having a high HSCL-25 score, adjusted for gender, low socioeconomic status (SES), using tobacco, participating in therapy and using antidepressants daily.

CONCLUSIONS

Both daily smoking and daily snus use were associated with an increased level of mental health problems. The adjusted probability for mental health problems was lower for snus use; however, snus use prevalence was tenfold in our sample.

IMPLICATIONS

Despite the lack of causal and directional conclusions, these associations may have implications for future legislation on snus. They also highlight the importance of more research, especially as snus is considered less harmful and seemingly replacing smoking in Norway.

Nicotine Content in Swedish-Type Snus Sold in Norway From 2005 to 2020

INTRODUCTION

Use of snus (moist smokeless tobacco) is widespread in Scandinavia and increasingly popular in the U.S. Snus products vary in terms of product design, portion size, and nicotine content. The aim of this study was to examine variations in the nicotine content in snus sold on the Norwegian market from 2005 to 2020.

METHODS

We calculated the nicotine content in dry snus in milligram per gram (mg/g) and milligram per serving (mg/s), weighted by the products' market share from data on nicotine content, water content, and portion size (both for portion and loose snus) for the ten most sold snus products from each of the three largest manufacturers in 2005, 2010, 2015, and 2020.

RESULTS

In all snus products combined, the nicotine content per gram snus (mg/g) increased from 16.3 to 24.1, while nicotine per serving (mg/s) was stable around 13.0. In portion snus, the nicotine content increased for both mg/g and mg/s, most notably from 2005 to 2010. In loose snus, mg/g decreased marginally, while mg/s was stable throughout the period.

CONCLUSIONS

In a period with increasing snus use, the nicotine content in snus increased per gram snus, but not per serving. The stability in nicotine per serving is likely due to a decreasing market share of loose snus which accounted for 54% of the snus products in 2005 and 5% in 2020, and which traditionally has a high content of nicotine per serving.

IMPLICATIONS

Use of snus is popular in Scandinavia, most notably in Sweden and Norway, but also increasingly common in Finland, especially among young adults. There are no prior market-based studies of variations in the nicotine content in Swedish snus over time. We found that the average amount of nicotine per gram snus sold on the Norwegian market increased in the period 2005 to 2020, most notably from 2005 to 2010, while the amount of nicotine per serving was stable in the same period, primarily due to a decreasing share of loose snus.

Use of Tobacco and Nicotine Products among Young People in Denmark-Status in Single and Dual Use

Lots of new tobacco or nicotine products are being launched, e.g., e-cigarettes and smokeless tobacco, which appeal especially to the youngest part of the population. For example, the use of smokeless tobacco among Danish youth rose from approx. 2% in 2010 to 9% in 2020. Hence, there is an urgent need to follow and intervene against youth tobacco or nicotine product use. This study explored the current use of cigarettes, e-cigarettes, heated tobacco, and smokeless tobacco among Danish 15- to 29-year-olds. Further, we examined the concurrent use of two products or more. We used a nationwide survey conducted among 15- to 29-year-olds in February and March 2020. Overall, approx. 35,700 individuals received the questionnaire of which 35.5% responded (n = 13,315). One out of five (20.1%) smoked cigarettes, half of them daily, the other half occasionally. About one in twenty (3.9%) used e-cigarettes (daily or occasionally), and more than one in three (31.6%) had tried e-cigarettes. The use of heated tobacco among Danish youth is still relatively limited (0.3%). In comparison, about 9% used smokeless tobacco (daily or occasionally). Overall, 27.0% stated that they use at least one type of tobacco or nicotine product, while 5.6% used more than one product. Monitoring tobacco-related behavior in youth provides extremely important information for, e.g., policymakers and health professionals.

Prevalence, duration of exposure and predicting factors for snus use among young Finnish men: a cross-sectional study

OBJECTIVE

The health hazards of tobacco products depend on the level of exposure, but little is known about the characteristics of snus use. The aim of this study was to investigate the duration of daily exposure to snus among occasional and daily users and its associated predictive factors among young Finnish men.

DESIGN

Cross-sectional questionnaire study.

SETTING

Three out of 16 Finnish Defence Forces units.

PARTICIPANTS

1280 young Finnish male conscripts starting their military service in 2016 chosen by simple random sampling.

PRIMARY AND SECONDARY MEASURES

The prevalence, duration of use and the amount of daily usage of snus and cigarettes were investigated. The attitudes towards perceived harmfulness of snus and the predictive factors affecting the total time of snus consumption were examined.

RESULTS

Almost a fifth (19.5%) of the conscripts reported daily snus use, and a further 16% reported occasional use. Daily snus use was associated with an earlier starting age, longer duration of use and higher daily exposure time compared with occasional use. On average, daily snus users consumed 10 portions and occasional users three portions per day (p<0.001). The daily total exposure time for daily users was 372 min (95% CI 344 to 401) and for occasional users 139 min (95% CI 106 to 171). Respondents with an upper secondary education had significantly less daily total exposure than those with basic comprehensive education (p=0.036). Perceptions of snus as a harmful substance resulted in a significantly lower duration of exposure.

CONCLUSION

Snus use was very common among young Finnish men. High snus exposure duration was associated with an earlier starting age, a longer history of use and a careless attitude to its health hazards. A higher education level was a protective factor for total exposure time. Studies of the long-term health effects and dependency profile of snus use are needed.

Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

METHODS

We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

FINDINGS

In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1·21% [-1·26 to -1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0·94% [-1·72 to -0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

INTERPRETATION

Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

COVID-19 among young adults in Sweden: self-reported long-term symptoms and associated factors

Aims:

The main aim of the study was to describe self-reported symptoms of COVID-19 and examine if long-term symptoms are associated with lifestyle factors or common chronic diseases among Swedish young adults. A secondary aim was to compare the prevalence of smoking and snuff use before and during the COVID-19 pandemic.

Methods:

The study population includes 1644 participants aged 23–26 years from the Swedish population-based birth cohort BAMSE. From August to November 2020, the participants answered a web questionnaire on COVID-19 symptoms, lifestyle and health. Information on tobacco use was compared against the previous study follow-up in 2016–2019.

Results:

The prevalence of suspected COVID-19 symptoms was 45.3% (n=742), and 80 of these (10.8%) reported long-term symptoms (⩾4 weeks). There was no significant difference in sociodemographic or lifestyle factors in relation to the duration of suspected COVID-19 symptoms. Rhinitis, migraine and lower self-rated health before the pandemic was more common among participants with long-term symptoms. In addition, there was a tendency for higher prevalences of asthma, chronic bronchitis and depression in this group. The prevalence of smoking decreased from 18.9% before the pandemic to 14.7% during the pandemic, while snuff use increased from 12.7% to 22.4% (P<0.001).

Conclusions:

Almost half of Swedish young adults have had symptoms of suspected COVID-19 from February up to August 2020. Among these, one out of 10 have had long-term symptoms for at least 4 weeks. Long-term symptoms of suspected COVID-19 were associated with several common chronic conditions. Smoking may have decreased during the pandemic, while snuff use may have increased.

Identification of biomarkers specific to five different nicotine product user groups: Study protocol of a controlled clinical trial

Background

Assessing biomarker profiles in various body fluids is of large value to discern between the sole use of nicotine products. In particular, the assessment of the product compliance is required for long-term clinical studies. The objective of this study was the identification of biomarkers and biomarker patterns in body fluids, to distinguish between combustibles, heated tobacco products, electronic cigarettes, oral tobacco and oral/dermal nicotine products used for nicotine replacement therapy (NRT), as well as a control group of non-users.

Methods

A controlled, single-center study was conducted with 60 healthy subjects, divided into 6 groups (5 nicotine product user groups and one non-user group) based on their sole use of the products of choice. The subjects were confined for 76 h, during which, free and uncontrolled use of the products was provided. Sample collections were performed according to the study time schedule provided in Table 2. The primary outcome will be validated through analysis of the collected biospecimens (urine, blood, saliva, exhaled breath and exhaled breath condensate) by means of untargeted omics approaches (i.e. exposomics, breathomics and adductomics). Secondary outcome will include established biomarker quantification methods to allow for the identification of typical biomarker patterns. Statistical analysis tools will be used to specifically discriminate different product use categories.

Results/Conclusions

The clinical trial was successfully completed in May 2020, resulting in sample management and preparations for the quantitative and qualitative analyses. This work will serve as a solid basis to discern between biomarker profiles of different nicotine product user groups. The knowledge collected during this research will be required to develop prototype diagnostic tools that can reliably assess the differences and evaluate possible health risks of various nicotine products.

Effects of smokeless tobacco on cell viability, reactive oxygen species, apoptosis, and inflammatory cytokines in human umbilical vein endothelial cells

Smokeless tobacco products provide an alternative to cigarettes; however, smokeless tobacco is carcinogenic and harmful to human health. This study evaluated the toxicological effects of snus extracts and cigarette smoke total particulate matter (TPM) on human umbilical vein endothelial cells (HUVECs). Treated cells were examined for cell viability, reactive oxygen species (ROS), apoptosis, and inflammatory cytokines. Moreover, we explored the mechanism of programmed cell death induced by snus. The results showed that snus extracts significantly inhibited cell viability in a dose-dependent manner. ROS was significantly increased in treatment groups, and anti-oxidant treatment could not prevent snus extract-induced cell death. Snus extracts induced apoptosis, DNA damage, activation and cleavage of caspase-3 and caspase-8, pathway-related gene change, and interleukin (IL)-6 and IL-8 release in HUVECs. Snus extracts exposure may induce cytotoxicity, ROS generation, inflammatory cytokines release, and apoptosis or DNA damage through intrinsic and extrinsic pathways in HUVECs.

Key Drivers to Implement an Evidence-based Tobacco Control Programme in Schools of India: A Mixed-Methods Study

Background:

Adolescence is an influential stage in students’ lives when lifelong behaviours such as tobacco use are formed. During these years, school teachers are important role models for tobacco control among students. A study was conducted among school personnel and administrators to understand the key drivers for implementing an evidence-based school tobacco control program.

Methodology:

A cross-sectional, mixed-method study was conducted in five districts of Assam, India. The quantitative study was conducted among 565 school personnel across 40 Government-aided schools. Data was collected by means of an anonymous, self-administered questionnaire. Qualitative data was generated from 15 focus group discussions (FGDs) among 146 participants - District Program Officers, Block Education Officers, Cluster Coordinators, Headmasters and Teachers.

Results:

While the prevalence of smoked tobacco was low (3%), the use of smokeless tobacco was higher (40%), and the prevalence of use of areca nut without tobacco (65%) was still higher among school personnel. They were aware of the school policies prohibiting the use of tobacco among students within or outside school buildings or during school-sponsored activities (81%); they had rather limited knowledge about policy for themselves (58%). There was lack of access to training materials about prevention of tobacco use among youth. The FGDs amongst school personnel resulted in several constructive suggestions on tobacco control in schools mainly in training school teachers, monitoring the program and incentives for execution of the program. However, there was a reluctance to implement a smokeless tobacco control programme since many were current users of smokeless tobacco and areca nut.

Conclusion:

Tobacco control policies as well as training school personnel in schools need to improve and further measures must be taken to prohibit use of areca nut, which contains carcinogens. The existing system of the education department can be utilised to implement tobacco control programmes effectively.

Predictors of electronic cigarette use among Swedish teenagers: a population-based cohort study

OBJECTIVES

The aim was to identify predictors of electronic cigarette (e-cigarette) use among teenagers.

DESIGN AND SETTING

A prospective population-based cohort study of schoolchildren in northern Sweden.

PARTICIPANTS

In 2006, a cohort study about asthma and allergic diseases among schoolchildren started within the Obstructive Lung Disease in Northern Sweden studies. The study sample (n=2185) was recruited at age 7-8 years, and participated in questionnaire surveys at age 14-15 and 19 years. The questionnaire included questions about respiratory symptoms, living conditions, upper secondary education, physical activity, diet, health-related quality of life, parental smoking and parental occupation. Questions about tobacco use were included at age 14-15 and 19 years.

PRIMARY OUTCOME

E-cigarette use at age 19 years.

RESULTS

At age 19 years, 21.4% had ever tried e-cigarettes and 4.2% were current users. Among those who were daily tobacco smokers at age 14-15 years, 60.9% had tried e-cigarettes at age 19 years compared with 19.1% of never-smokers and 34.0% of occasional smokers (p<0.001). Among those who had tried e-cigarettes, 28.1% were never smokers both at age 14-15 and 19 years, and 14.4% were never smokers among the current e-cigarette users. In unadjusted analyses, e-cigarette use was associated with daily smoking, use of snus and having a smoking father at age 14-15 years, as well as with attending vocational education, physical inactivity and unhealthy diet. In adjusted analyses, current e-cigarette use was associated with daily tobacco smoking at age 14-15 years (OR 6.27; 95% CI 3.12 to 12.58), attending a vocational art programme (OR 2.22; 95% CI 1.04 to 4.77) and inversely associated with eating a healthy diet (OR 0.74; 95% CI 0.59 to 0.92).

CONCLUSIONS

E-cigarette use was associated with personal and parental tobacco use, as well as with physical inactivity, unhealthy diet and attending vocational upper secondary education. Importantly, almost one-third of those who had tried e-cigarettes at age 19 years had never been tobacco smokers.

High-Sensitivity Cardiac Troponin I and T Response Following Strenuous Activity is Attenuated by Smokeless Tobacco: NEEDED (North Sea Race Endurance Exercise Study) 2014

Background

Use of snus, a smokeless tobacco product, is increasing in Scandinavia. Strenuous physical activity is associated with an acute increase in high‐sensitivity cardiac troponin (swhs‐cTn) concentrations. Current smoking is associated with lower hs‐cTn, but whether this also holds true for smokeless tobacco and whether tobacco affects the hs‐cTn response to exercise remain unknown.

Methods and Results

We measured hs‐cTnI and hs‐cTnT concentrations in 914 recreational athletes before and 3 and 24 hours after a 91‐km bicycle race. Self‐reported snus tobacco habits were reported as noncurrent (n=796) and current (n=118). The association between snus use and change in log‐transformed hs‐cTnI and hs‐cTnT concentrations (ie, the differences between concentrations at baseline and 3 hours and 24 hours ) were assessed by multivariable linear regression analysis. Concentrations of hs‐cTn at baseline were lower in current than in noncurrent snus users (hs‐cTnI median, 1.7 ng/L; Q1 to Q3: 1.6–2.3 versus 2.0 ng/L; Q1 to Q3: 1.6–3.2 [P=0.020]; and hs‐cTnT: median, 2.9 ng/L, Q1 to Q3: 2.9–3.5 versus 2.9 ng/L, Q1 to Q3: 2.9–4.3 [P=0.021]). In fully adjusted multivariable models, use of snus was associated with lower change in hs‐cTn concentrations from baseline to 3 hours (hs‐cTnI: −29% [P=0.002], hs‐cTnT: −18% [P=0.010]) and 24 hours (hscTnI: −30% [P=0.010], hs‐cTnT −19%, [P=0.013]).

Conclusions

Resting hs‐cTn concentrations are lower and the exercise‐induced cardiac troponin response is attenuated in current users of smokeless tobacco compared with nonusers. Further insight into the pathophysiological processes underlying the attenuated cardiac troponin response to exercise in tobacco users is needed.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02166216.

Cue salience of the use of an electronic nicotine delivery system (ENDS) device marketed to women

INTRODUCTION

Passive exposure to the use of electronic nicotine delivery systems (ENDS or e-cigarettes) has been shown to generalize as a smoking cue. As young adult women in particular are increasingly targeted by ENDS distributors, the present study examined whether passive exposure to the use of a female-marketed ENDS product selectively enhanced smoking urge, cigarette and e-cigarette desire, and smoking behavior among women (vs men) smokers.

METHODS

Using a mixed design, young adult smokers (n = 64; mean age 28.2 yrs.; ≥5 cigarettes/day) observed a study confederate drink bottled water (control cue) and then vape a female-marketed tank-based ENDS (active cue). Main measures were the Brief Questionnaire of Smoking Urges (BQSU) and visual analog scales (VAS) for cigarette and e-cigarette desire pre- and post-cue exposure, followed by a smoking latency task.

RESULTS

Compared to the control cue, the female-marketed ENDS cue increased smoking urge and desire for cigarettes and e-cigarettes to a similar extent in women and men. It also affected subsequent smoking behavior similarly between the sexes, with 68% of men and 58% of women opting to smoke (vs. obtaining monetary reinforcers).

CONCLUSIONS

Both women and men were sensitive to the use of the female-marketed ENDS as a smoking cue. Consistent with prior work by our group, findings demonstrate the cue salience of ENDS, which may be attributable to the aspects of vaping that resemble traditional smoking (e.g. hand-to-mouth and inhalation and exhalation behaviors).

Alarming development of dual snus and cigarette usage among young Finnish males

Background

The consumption of tobacco products has evolved to include more complex combinations of different products. We investigated the tobacco habits of a representative population of young Finnish male conscripts in order to evaluate the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another. In addition, we evaluated the correlation between the level of education and the use of cigarettes and snus.

Methods

A questionnaire-based survey was carried out in three out of 17 garrisons among conscripts during their first week of service in 2014. A total of 1971 male conscripts were selected by simple random sampling of the 9013 males in the selected garrisons. Of them 1916 participated and filled in the questionnaire. The response rate was 97.2%. The questionnaire consisted of 25 questions including age, gender, basic education, use of tobacco products as well as questions assessing nicotine dependency.

Results

The amount of dual users of cigarettes and snus was 21%. There was a higher probability of dual use of cigarettes and snus among smokers compared to snus users (p < 0.001). One third (35%) of former smokers reported daily snus use and over 40% of the former snus users smoked daily. One third (34%) of the participants reported snus usage and 14% of the study subjects used snus daily. 40% of the study population were smokers and over 25% smoked daily. Of the participants with basic educational background 57% smoked daily (p < 0.001), however, no association between snus and level of education was found (p = 0.69).

Conclusions

This study provides better understanding of the complex tobacco habits of young adult males. The simultaneous usage of multiple tobacco products as well as the high tendency to transition from one tobacco product to another should be taken into consideration when planning cessation interventions in health care settings and tobacco control policies at societal levels.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7519-1) contains supplementary material, which is available to authorized users.

An update on prevalence and risk of snus and nicotine replacement therapy during pregnancy and breastfeeding

AIM

In parallel with falling smoking rates, use of the oral moist tobacco product snus increases among women in reproductive age. We report an update on prevalence and effects of maternal use of snus and nicotine replacement therapy (NRT) during pregnancy and breastfeeding.

METHODS

A literature search of human studies in Medline, PubMed and EMBASE was conducted from September 2016 to May 2018, with stepwise screening of abstracts and subsequent relevant full-text papers for inclusion in Scandinavian and English languages.

RESULTS

Based on three studies, the prevalence of snus use in pregnancy was up to 3.4% in the first trimester and 2.1% in the third trimester. In 12 studies, we found increased risk of several adverse effects, especially preterm delivery, stillbirth and small for gestational age associated with maternal snus use during pregnancy. Knowledge on effects of NRT during pregnancy was conflicting and inconclusive in 10 studies. We did not identify any studies on prevalence or potential health effects of snus or NRT during breastfeeding.

CONCLUSION

Few studies with updated data on the prevalence and adverse health effects of maternal use of snus and NRT during pregnancy were found. No studies during breastfeeding were identified.

Snus users had high levels of nicotine, cotinine and 3-hydroxycotinine in their breastmilk, and the clearance was slower than in smoking mothers

AIM

Using snus, an oral moist tobacco, has increased among pregnant women in Sweden, the only European Union country where sales are legal. This study evaluated whether snus generated similar concentrations of nicotine and its metabolites in breastmilk to cigarette smoking.

METHODS

We analysed 49 breastmilk samples from 33 nursing mother - 13 snus users, six cigarette smokers and 14 controls - for concentrations of nicotine, cotinine and 3-hydroxycotinine. The mothers were recruited at antenatal clinics in Sweden from 2007 to 2012.

RESULTS

The median nicotine concentration in breastmilk of the snus users was 38.7 ng/mL (0-137) versus 24.0 ng/mL (0-56) in smokers, with median cotinine levels of 327.6 ng/mL (37-958) versus 164.4 ng/mL and median 3-hydroxycotinine levels of 202.7 ng/mL (28-452) versus 112.4 (0-231), respectively. Nicotine was still detected in the breastmilk of eight of the 13 snus users after abstaining from tobacco for a median duration of 11 hours (0.6-12.5), while the breastmilk of the smokers was nicotine-free after four hours' abstinence.

CONCLUSION

Snus users had high levels of nicotine and metabolites in their breastmilk and nicotine was found even after 12.5 hours of abstinence.

Stopping when knowing: use of snus and nicotine during pregnancy in Scandinavia

The risk of adverse health effects in offspring due to maternal tobacco smoking during pregnancy is well documented [1], including epigenetic changes persisting in the offspring after prenatal exposure [2]. The effects of fetal exposure to nicotine from non-combustible tobacco products, such as snus or nicotine-replacement therapies (NRTs), are less clear. Use of snus leads to systemic absorption of nicotine into the maternal circulatory system, with subsequent exposure of the foetus through the placenta [3].

In young women, the use of snus increases in parallel with decreasing smoking rates but the  use in pregnancy is unclear. Our aims were to determine the prevalence of snus use, smoking and other nicotine-containing product use during pregnancy, and to identify predictors for snus use in pregnancy.

Prevalence was determined for 2528 women in Norway and Sweden based on the Preventing Atopic Dermatitis and ALLergies (PreventADALL) study, a population-based, mother–child birth cohort. Electronic questionnaires were completed in pregnancy week 18 and/or week 34, and potential predictors of snus use were analysed using logistic regression models.

Ever use of any snus, tobacco or nicotine-containing products was reported by 35.7% of women, with similar rates of snus use (22.5%) and smoking (22.6%). Overall, 11.3% of women reported any use of nicotine-containing products in pregnancy up to 34 weeks, most often snus alone (6.5%). Most women (87.2%) stopped using snus by week 6 of pregnancy.

Snus use in pregnancy was inversely associated with age and positively associated with urban living and personal or maternal history of smoking. While 11.3% of women used snus or other nicotine-containing products at some time, most stopped when recognising their pregnancy. Younger, urban living, previously smoking women were more likely to use snus in pregnancy.

Of the 11.3% of women using any nicotine products in pregnancy (most often snus (6.5%)), the majority stop within pregnancy week 6. Snus use is associated with urban living, previous smoking, in utero smoking exposure of the index woman and lower age.http://ow.ly/Gyg230nmxIo

Differential Impact According to Mission's Operational Intensity on Psychoactive Substance Use: A Retrospective Cohort of French Male Army Service Members

BACKGROUND

Stressful deployments in combat areas are known to increase the risk of substance abuse in military personnel.

OBJECTIVES

The aim of the study was to compare deployment on stressful, high-intensity missions (HIMs) to deployment on low-intensity missions (LIMs) in order to understand factors associated with substance use variations across the mission.

METHODS

A retrospective cohort study based on a one-shot self-questionnaire was performed four months after their return on two samples of male French Army service members: one returning from an HIM and one from an LIM. The questionnaire focused on tobacco, alcohol, cannabis, cocaine, and psychoactive medication use at three times: before, during, and after the mission.

RESULTS

During an HIM, the frequency of tobacco use increased, alcohol use remained stable - although 38% declared a decrease in consumption - and illicit drug use decreased. During an LIM, tobacco and alcohol use increased, cannabis use remained stable, and only cocaine and medication use decreased. After their return, use levels among both samples reverted to values similar to those reported before the mission, except for a decrease in tobacco use observed at return from an HIM. The main factors perceived as related to variations were stress in an HIM and low cost in an LIM. Conclusions/importance: The study suggests a differential impact of deployment on substance use according to the operational intensity of the mission. Variations in use are predominant during the mission with a washout effect after returning home.

Exercise performance increase in smokeless tobacco-user athletes after overnight nicotine abstinence

The use of nicotine administered through smokeless tobacco (snus) has increased among athletes. The purpose of this study was to investigate the ergogenic effects of snus on aerobic performance during exercise until exhaustion in athletes after abstinence or satiety nicotine conditions. The study utilized a randomized, controlled, within-subject design experiment. Sixteen male snus-user athletes completed an exercise until exhaustion at a constant load of their 80% of V ˙ O 2 max (calculated by a maximal incremental test) in two separate sessions, corresponding to nicotine conditions: 12-hour overnight abstinence and satiety. A portion of 1 g of snus (~8 mg/g of nicotine) was administered 25 minutes before each experimental test. In each session, time to exhaustion (TTE), global rating of perceived exertion, cardiovascular and metabolic responses, and muscle and cerebral oxygenation were measured. Nicotine and cotinine analysis confirmed session conditions (abstinence or satiety). Snus induced a significant increase (+13.1%) of TTE following abstinence (24.1 ± 10.7 minutes) compared to satiety condition (20.9 ± 8.0 minutes; P = 0.0131). The baseline values revealed that abstinence of snus induced significant increase in the oxygenation of the muscular tissues (+4%), in metabolic values and in cardiovascular parameters, when compared to satiety condition. Our results indicate an increase of exercise performance (+13.1% TTE) due to snus administration in an abstinence condition. Considering that twelve hours of abstinence from snus-contained nicotine affected metabolic, cardiovascular and muscular tissue oxygenation, we suggest that snus administration at test time might relieve these withdrawal changes and yield an increase in time to exhaustion.

Tobacco and electronic cigarette products: awareness, cessation attitudes, and behaviours among general practitioners

BACKGROUND

Little is known around how general practitioners (GP) approach tobacco products beyond traditional cigarettes.AimTo examine GP perceptions of tobacco and electronic cigarette (EC) products, and their attitudes and behaviours towards product cessation.

METHOD

A 13-item self-completed anonymous questionnaire measured awareness of waterpipe tobacco smoking (WTS) and smokeless tobacco (ST). Cessation advice provision, referral to cessation services, and the harm perception of these products were asked using five-point Likert scales that were dichotomised on analysis. Correlates of cessation advice were analysed using regression models.FindingsWe analysed 312 responses, of whom 63% were aware of WTS and between 5-32% were aware of ST products. WTS and ST were considered less harmful than cigarettes by 82 and 68% of GPs, respectively. WTS, ST, and EC users were less advised (P<0.001) and referred (P<0.001) to cessation services compared to cigarette users. Ethnic minority and senior GPs were more likely to provide cessation advice for WTS and ST users compared to younger white GPs. GPs who were recent tobacco users were less likely to give cessation advice to cigarette users (adjusted odds ratios 0.17, 95% confidence interval 0.03-0.99, P<0.049).Conclusions (implications for practice and research)GPs had lower harm perception, gave less cessation advice, and made less referrals for WTS and ST users compared to cigarettes. Our findings highlight the need for targeted tobacco education in general practice. More research is needed to explore GP perceptions in depth as well as patient perspectives.

Otorhinolaryngological symptoms among smokeless tobacco (Maras powder) users

OBJECTIVE:

This study aims to investigate the relationship between smokeless tobacco (maras powder) consumption and otorhinolaryngological symptoms.

METHODS:

This descriptive study was carried out on 599 participants. The participants were divided into two groups. Of these, 299 (49.9%) patients aged over 18 years were the first group; they used smokeless tobacco for at least 5 years. The remaining patients comprised the second group, which included 300 (50.1%) healthy volunteers who did not use tobacco or its products and demonstrated some similarities with the first group. For the purpose of data collection, a questionnaire consisting of 45 questions was administered to the participants.

RESULTS:

Cough, sputum, shortness of breath, dysphagia, snoring, and apnea-hypopnea were found to be significantly increased in smokeless tobacco users. The highest odds ratio (OR) found was for sputum at 2.615. Similarly, other oral cavity symptoms such as mouth tickling, dryness of throat, mouth sores, halitosis, taste disorders, and toothache were found to be significantly increased in smokeless tobacco users. It is noteworthy that halitosis was 9.4 times more prevalent among smokeless tobacco users than in the non-tobacco users. Sinonasal symptoms such as sneezing, headache, facial fullness, and anorexia were found to be significantly increased in smokeless tobacco users. However, there were no differences between the groups in terms of ear symptoms.

CONCLUSION:

This study demonstrated that the negative effects of smokeless tobacco consumption were particularly higher in the oral cavity, which in turn gave rise to a number of serious upper respiratory tract complaints.

A Preliminary Investigation on Smokeless Tobacco Use and Its Cognitive Effects Among Athletes

Introduction: Among athletes, an increasing use of nicotine via smokeless tobacco has been reported. However, there are currently unanswered questions about whether the use by athletes is due to nicotine’s addictive properties and/or to benefits in physical and cognitive performance (e.g., decision-making). In this original article we reported about, (i) snus-induced reinforcing effects among snus-user athletes (Survey) and (ii) the effects of snus on the Iowa Gambling Task (IGT) in snus-user skiers (Experimental study). IGT is an experimental neuropsychological task that has been previously used on athletes and addicts to test decision-making.

Methods: Survey: data were collected with the modified Cigarette Evaluation Questionnaire (mCEQ) that was administered to 61 winter sport athlete snus-users in Northern Italy. Experimental study: IGT data included: amount of money earned, number of choices from advantageous and disadvantageous decks and overall net score. Eighteen male snus-users were tested under satiety or after 12-h abstinence conditions according to a crossover design.

Results: Survey: the comparison between occasional vs. regular snus-users showed a statistically significant difference in satisfaction (P = 0.0088), calm (P = 0.0252), and enjoyment (P = 0.0001) mCEQ items suggesting a snus intake/effect relationship. Experimental study: significantly higher IGT net scores were found during the first 20 choice cards after abstinence vs. satiety conditions (P = 0.0024).

Conclusion: In the Survey, regular snus use induces greater satisfaction and psychological reward than occasional use. In the Experimental study, snus intake might produce an early and transient cognitive improvement on IGT in abstinent snus-users, presumably acting as a withdrawal relief.

Spousal concordance in the use of alternative tobacco products: A multi-country investigation

BACKGROUND

Married couples often share similar health-related characteristics and behaviors, including cigarette smoking status. Despite their rising popularity in the U.S., little research has examined the patterns of spousal concordance (SC) for alternative tobacco products (ATPs), such as e-cigarettes, cigars, and hookah.

METHODS

The purpose of this project was to examine the roles of age, gender, and culture in the strength of SC for these ATPs. Analyses focused on a diverse community sample of married individuals in Ohio, U.S. (N=278), but also examined patterns in Austria, Greece, Israel, the Netherlands, and Slovakia. All participants completed a survey in which they indicated both their own, and their spouse's ever-use of various tobacco products.

RESULTS

For the U.S. sample, SC was highest for e-cigarettes, flavored e-cigarettes, flavored cigarettes, and hookah (ϕs=0.48- 0.61); SC appeared to be stronger among younger couples, and when there was only a small female vs. male differences in use. Similar patterns were found in the other countries, with a few key exceptions. In particular, there was low SC for e-cigarettes and flavored e-cigarettes in the other countries, where e-cigarettes had been federally regulated by the time of data collection.

CONCLUSION

Overall, these findings have implications for the continued spreading popularity of these tobacco use behaviors.

Effects of cigarette smoking on cardiovascular-related protein profiles in two community-based cohort studies

BACKGROUND AND AIMS

Cardiovascular diseases account for the largest fraction of smoking-induced deaths. Studies of smoking in relation to cardiovascular-related protein markers can provide novel insights into the biological effects of smoking. We investigated the associations between cigarette smoking and 80 protein markers known to be related to cardiovascular diseases in two community-based cohorts, the Prospective Study of the Vasculature in Uppsala Seniors (PIVUS, n = 969, 50% women, all aged 70 years) and the Uppsala Longitudinal Study of Adult Men (ULSAM, n = 717, all men aged 77 years).

METHODS

Smoking status was self-reported and defined as current smoker, former smoker or never-smoker. Levels of the 80 proteins were measured using the proximity extension assay, a novel PCR-based proteomics technique.

RESULTS

We found 30 proteins to be significantly associated with current cigarette smoking in PIVUS (FDR<5%); and ten were replicated in ULSAM (p < 0.05). Matrix metalloproteinase-12 (MMP-12), growth/differentiation factor 15 (GDF-15), urokinase plasminogen activator surface receptor (uPAR), TNF-related apoptosis-inducing ligand receptor 2 (TRAIL-R2), lectin-like oxidized LDL receptor 1 (LOX-1), hepatocyte growth factor (HGF), matrix metalloproteinase-10 (MMP-10) and matrix metalloproteinase-1 (MMP-1) were positively associated, while endothelial cell-specific molecule 1 (ESM-1) and interleukin-27 subunit alpha (IL27-A) showed inverse associations. All of them remained significant in a subset of individuals without manifest cardiovascular disease.

CONCLUSIONS

The findings of the present study suggest that cigarette smoking may interfere with several essential parts of the atherosclerosis process, as evidenced by associations with protein markers representing endothelial dysfunction, inflammation, neointimal formation, foam cell formation and plaque instability.