Socio-demographic, lifestyle and health characteristics among snus users and dual tobacco users in Stockholm County, Sweden

Patterns and Determinants of Exclusive Smokeless Tobacco (Snus) Use, Exclusive Smoking and Dual Use in General Population During 20 Years

BACKGROUND

We investigate smokeless tobacco (snus) use and its correlates over 20 years in a country where selling snus is prohibited but a large import quota and illicit market exists.

METHODS

Repeated cross-sectional population-based surveys during 2000 to 2020 in Finland, including N = 57 111 adults aged 20 to 64 years. The outcome measures were current tobacco use (exclusive snus use, dual use, exclusive smoking, no tobacco use) and snus use (daily, occasional, no snus use). Study years, gender, age, education, marital status, self-rated health, body mass index, and binge drinking were used as explanatory variables.

RESULTS

Exclusive snus use and dual use increased 3.6% units and 2.6% units from 2000 to 2005 and from 2018 to 2020, respectively. Overall decrease of tobacco use was led by decreasing exclusive smoking from 30.1% to 18.2%. The shared risk factors for snus use and dual use were male gender, age group 20 to 34 years, and binge drinking. The increases in snus and dual use over time were also most prevalent among these groups. Among men, occasional smoking increased the likelihood of daily (relative risk ratio [RRR] 2.38, 95% confidence interval [CI] 1.42, 3.99) and occasional (RRR 3.11, 95% CI 1.93, 5.03) snus use.

CONCLUSIONS

Snus use has increased among the general adult population in Finland during 2000 to 2020 yet remains less common than smoking. Snus use and dual use share some common risk factors. Snus use should be considered in cessation services, with support for quitting developed and targeted predominantly for men, younger adults, and persons drinking to intoxication.

Tobacco impact on quality of life, a cross-sectional study of smokers, snuff-users and non-users of tobacco

BACKGROUND

Tobacco smoking is a major public health issue, and also affects health-related quality of life. There has been considerable debate as to whether oral moist snuff, a form of tobacco placed in the oral cavity between the upper lip and gum as in sublabial administration, can be considered a safe alternative to smoking. The aim of this study was to investigate the association between health-related quality of life and smoking, snuff use, gender and age.

METHOD

This cross-sectional study included 674 women and 605 men aged 18 to 65 recruited through a Swedish population database. Subjects completed a questionnaire about tobacco use and the 36-item Short Form Health Survey (SF-36). Multivariable logistic regression analyses were performed for the association between health-related quality of life and tobacco use, gender and age. The median perceived health-related quality of life (SF-36) for an age-matched Swedish population was used as the cutoff: above the cutoff indicated better-than-average health coded as 1, or otherwise coded as 0. The independent variables were smoking (pack-decades), snuff-use (box-decades), gender and age in decades. The outcome was presented as the Odds Ratio (OR) with a 95% confidence interval (CI) for each independent variable.

RESULTS

The experience of cigarette smoking is associated with decreased physical functioning (PF), general health (GH), vitality (VT), social functioning (SF) and mental health (MH) as well as both lower physical component summary (PCS) and mental component summary (MCS). Further, the experience of snuff use is associated with bodily pain (BP), lower VT, and lower PCS. In the study population older age is associated with lower PF,GH, VT, MH, PCS and MCS. Female gender is associated with lower PF and VT.

CONCLUSION

This study shows that smoking is associated with lower health-related quality of life. The results also illuminate the detrimental health effects of using snuff, implying that snuff too is a health hazard. As studies on the bodily effects of snuff are relatively scarce, it is imperative that we continue to address and investigate the impact on the population using snuff on a regular basis.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT05409963 05251022 08/06/22.

'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.

Current tobacco use and COVID-19 diagnoses in a cohort of adult clients of public dental clinics in Sweden

Smoking has been linked with both increased and decreased risk of COVID-19, prompting the hypothesis of a protective role of nicotine in the pathogenesis of the disease. Studies of the association between use of smokeless tobacco and COVID-19 would help refining this hypothesis. We analysed data from 424,386 residents in the Stockholm Region, Sweden, with information on smoking and smokeless tobacco (snus) use prior to the pandemic obtained from dental records. Diagnoses of COVID-19 between February and October 2020 were obtained from health-care registers. We estimated the risk of receiving a diagnosis of COVID-19 for current smokers and for current snus users relative to non-users of tobacco, adjusting for potential confounders (aRR). The aRR of COVID -19 was elevated for current snus users (1.09 ;95%CI = 0.99-1.21 among men and 1.15; 95%CI = 1.00-1.33 among women). The risk for women consuming more than 1 can/day was twice as high as among non-users of tobacco. Current smoking was negatively associated with risk of COVID-19 (aRR = 0.68; 95% CI = 0.61-0.75); including hospital admission (aRR = 0.60; 95% CI = 0.47-0.76) and intensive care (aRR = 0.43; 95% CI = 0.21-0.89). The hypothesis of a protective effect of tobacco nicotine on COVID-19 was not supported by the findings. The negative association between smoking and COVID-19 remains unexplained.

The relationship between smokeless tobacco (snus) and anxiety and depression among adults and elderly people. A comparison to smoking in the Tromsø Study

AIMS

To (i) define the characteristics of snus users compared with non-users and smokers and (ii) define the relationship between snus use and self-reported anxiety and depression and compare it with the relation between smoking and anxiety and depression.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional study based on data from the Norwegian population-based survey, the Tromsø Study (2015-16). A total of 32 591 people aged 40 years and older in the municipality of Tromsø were invited to attend. There were 21 083 respondents, giving a 65% attendance rate.

MEASUREMENTS

Tobacco use was assessed by current and previous use of snus or cigarettes. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS).

FINDINGS

Snus users were more often male, were younger and had higher income and higher alcohol consumption than smokers and non-users of snus. In a linear regression analysis, we found no significant association between current snus use and anxiety and depression after adjusting for background variables. However, there was a positive association between previous snus use and anxiety among males [adjusted beta = 0.258; 99% confidence interval (CI) = 0.023-0.492]. Regarding anxiety, the adjusted beta-coefficients for current smoking were 0.425 (99% CI = 0.184-0.666) for females and 0.303 (99% CI = 0.084-0.522) for males. Concerning depression, the adjusted beta coefficients for current smoking were 0.569 (99% CI = 0.358-0.780) for females and 0.281 (99% CI = 0.060-0.503) for males.

CONCLUSIONS

In Norway, current snus users differ from current smokers by having a higher socio-economic status and no detectable association with anxiety and depression. This suggests that the relationship between tobacco use and anxiety and depression is associated with the administration method.

Smoking and snus use among Norwegian students: Demographic, personality and substance use characteristics

Background and aim:

Smoking rates are decreasing in Norway while the use of snus has increased. We aimed to investigate the co-occurrence of, and the socio-demographics, personality and substance use characteristics associated with, student smoking and snus use.

Methods:

Survey data were collected among students in higher education in Bergen, Norway in 2015 (N = 11,236, response rate 39.4%). Multinomial regression analyses comparing snus users and smokers to non-users and non-smokers, respectively, on demographic, personality and substance use variables were conducted. Regression analyses comparing current dual users to current smokers and current snus users and comparing daily smokers to daily snus users, on demographic, personality and substance use variables were also conducted.

Results:

In total 67.9% of ever snus users identified themselves as non-smokers (past and current). Several demographic, personality and substance use characteristics associated with smoking and snus use were identified (all = p < .05), some of which were common for both (e.g., use of cannabis) and some which were exclusively associated with either smoking (e.g., neuroticism) or snus use (e.g., extroversion).

Conclusion:

The current study contributes with several novel findings regarding traits associated with smoking and snus use. Though limited by a cross-sectional design, the current findings may suggest that the group of students using snus consists of a combination of previous smokers, students who would have smoked if snus was not available and a new segment who may not have used nicotine if snus was not available.

Snus and Alcohol: Mutually Rewarding Effects in the Brain? A Matched Controlled Population Study

Background:

The use of moist smokeless tobacco (snus) is increasing in the U.S. and other Western countries, and especially among young people. Snus is associated with several health problems, but the relationship between use of snus and alcohol is scarcely explored. Neuro-cognitive and psychological research suggest an association due to possible mutually rewarding effects in the limbic brain. We investigated this issue in a matched controlled population study.

Methods:

Matched control group design where drinking habits and alcohol consumption in a group of users of snus (n = 1043, mean age = 35.20; n men = 749, n women = 294) were compared to a control group of non-users matched on age and gender (n = 1043, mean age = 35.65; n men = 749, n women = 294). In addition, we registered background variables such as level of education, income, self-perceived general, dental health, mental health, current depressive symptoms, and BMI. In estimation of alcohol consumption, the background variables were used as covariates in factorial analyses of variance (ANCOVA).

Results:

Users of snus had lower level of education, lower income, poorer general, dental, and mental health status than non-users, but there were no differences in BMI. Differences in mental health status were related to drinking habits. Users of snus had a higher frequency of drinking, higher frequency of intoxication, and showed more excess drinking. Controlled for background variables users of snus had a 25.2% higher estimated yearly consumption of alcohol in terms of standard units of alcohol on the weekdays, 26.4% higher on weekends and a 60.2% higher yearly excess consumption.

Conclusion:

Users of snus had an elevated alcohol consumption and another drinking style than non-users. The findings are discussed according to neuro-cognitive and psychopharmacological mechanisms, reward learning and conditioning. The results have implications for prevention, treatment and rehabilitation of alcohol and nicotine dependence.

Older age, smoking, tooth loss and denture-wearing but neither xerostomia nor salivary gland hypofunction are associated with low intakes of fruit and vegetables in older Danish adults

Xerostomia and salivary gland hypofunction are prevalent conditions in older people and may adversely influence the intake of certain foods, notably fruit and vegetables. Here, we aimed to investigate whether xerostomia and salivary gland hypofunction were associated with a lower intake of fruit and vegetables. The study included 621 community-dwelling adults, mean age 75⋅2 ± 6⋅4 years, 58⋅9 % female, who had participated in the Copenhagen City Heart Study follow-up, and undergone interviews regarding food intake (preceding month), oral and general health (xerostomia, taste alterations, diseases, medication, alcohol consumption and smoking), clinical oral examination and measurements of unstimulated and chewing-stimulated whole saliva flow rates. The average total energy intake (8⋅4 ± 2⋅7 MJ) and protein energy percentage (14⋅8 ± 3⋅1 %) were slightly below recommendations. The average fruit (234⋅7 ± 201⋅2 g/d) and vegetables (317⋅3 ± 157⋅4 g/d) intakes were within recommendations. Xerostomia and hyposalivation were more prevalent in women than in men (16⋅4 v. 7⋅1 %, P < 0⋅001 and 40⋅7 v. 27⋅5 %, P < 0⋅001). Multiple linear regression analyses revealed that older age (β -0⋅009, se 0⋅003, P = 0⋅005), smoking (β -0⋅212, se 0⋅060, P = 0⋅0005) and wearing complete dentures/being partially or fully edentulous (β -0⋅141, se 0⋅048, P = 0⋅003), but neither xerostomia nor salivary flow rates were associated with an inadequate fruit and vegetable intake, after adjustment for covariates. Older age, smoking, tooth loss and denture-wearing were stronger determinants of low fruit and vegetable intakes than xerostomia and salivary hypofunction supporting the importance of dietary counselling and maintenance of oral health and an adequate masticatory performance.

Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies

BACKGROUND

The health consequences of the use of Swedish snus, including its relationship with mortality, have not been fully established. We investigated the relationship between snus use and all-cause and cause-specific mortality (death due to cardiovascular diseases, cancer diseases and all other reasons, respectively) in a nationwide collaborative pooling project.

METHODS

We followed 169 103 never-smoking men from eight Swedish cohort studies, recruited in 1978-2010. Shared frailty models with random effects at the study level were used in order to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of mortality associated with snus use.

RESULTS

Exclusive current snus users had an increased risk of all-cause mortality (aHR 1.28, 95% CI 1.20-1.35), cardiovascular mortality (aHR 1.27, 95% CI 1.15-1.41) and other cause mortality (aHR 1.37, 95% CI 1.24-1.52) compared with never-users of tobacco. The risk of cancer mortality was also increased (aHR 1.12, 95% CI 1.00-1.26). These mortality risks increased with duration of snus use, but not with weekly amount.

CONCLUSIONS

Snus use among men is associated with increased all-cause mortality, cardiovascular mortality, with death from other causes and possibly with increased cancer mortality.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway

Background

As smoking rates decreased, the use of Swedish snus (smokeless tobacco) concordantly increased in Norway. The role of snus as possible contributor to the reduction of smoking has been widely discussed. Our aim was to quantitate transitions in snus use, smoking and dual use of snus and cigarettes in a young male population.

Methods

This prospective cohort study includes 1346 boys participating in the Nord-Trøndelag Health Study in Young-HUNT1 1995–97, age 13–19 and in HUNT3 2006–08, age 23–30. Participants reported on tobacco use at both points of time. Models with binominal regression were applied to examine relative risks (RRs), of adolescent ever snus users, dual users or smokers (reference: never tobacco use), to be current snus only users, smokers (including dual users), or tobacco free in adulthood.

Results

Current tobacco use in this male cohort increased from 27% in adolescence to 49% in adulthood, increasing more for snus only use and dual use than for smoking only.

The adjusted RR (95% CI) of becoming a smoker as young adult, was 2.2 (CI 1.7–2.7) for adolescent snus users, 3.6 (CI 3.0–4.3) for adolescent dual users, and 2.7 (CI 2.2–3.3) for adolescent smokers. RR to become snus only users as adults was 3.1 (2.5–3.9) for adolescent dual users, 2.8 (2.2–3.4) for adolescent snus users and 1.5 (1.0–2.2) for adolescent smokers. The adjusted RR for the transition from adolescent tobacco use to no tobacco use in adulthood was similar for snus users and smokers with RR 0.5 (CI 0.4–0.7), but considerably lower for dual users with RR 0.2 (CI 0.2–0.3).

Conclusions

The use of snus, with or without concurrent smoking, carried a high risk of adult smoking as well as adult snus only use. Dual use seemed to promote the opportunity to become snus only users in adulthood, but made it also more difficult to quit. The benefit of snus use for harm reduction is not evident in our cohort, as the combination of smoking and dual use resulted in high smoking rates among the young adults.

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.

Concurrent use of addictive substances among alcohol drinkers: Prevalence and problems in a Swedish general population sample

Aims:

To examine concurrent use of addictive substances among alcohol drinkers in the Swedish general population and to assess to what extent this increases the risk of alcohol problems.

Methods:

Data were retrieved from a nationally representative survey from 2013 on use of and problems related to alcohol, tobacco, illicit drugs and non-prescribed use of analgesics and sedatives with 15,576 respondents. Alcohol users were divided into different groups on the basis of frequency of drinking overall and binge drinking. Tobacco use was measured in terms of daily use and use of illicit drugs and non-prescribed use of analgesics and sedatives were measured in terms of last 12 months prevalence. A dichotomous indicator of a DSM-IV dependence or abuse diagnosis was used. Logistic regression models were estimated to examine the relationship between various patterns of drinking in combination with other substance use and risk of alcohol abuse and/or dependence.

Results:

People who drink alcohol in Sweden were more likely to use other addictive substances than non-drinkers and such concurrent use becomes more common the more alcohol is consumed. Alcohol drinkers using other substances have a higher prevalence of alcohol abuse and dependence at all frequencies of drinking. Multivariate models controlling for sex, age and drinking frequency found that an elevated risk of harm remained for drinkers using addictive substances other than snuff.

Conclusion:

A large group of drinkers in the Swedish general population have an accumulation of risks as a result of using both alcohol and other addictive substances. Concurrent use of cigarettes, illicit drugs and non-prescribed use of analgesics and sedatives adds an independent risk of alcohol abuse/dependence in this group in addition to their drinking. The findings point at the importance of taking multiple substance-use patterns into account when combating drinking problems. Screening for concurrent use of other addictive substances could help healthcare providers to identify patients in need of treatment for alcohol problems.

Association of snus experimentation in late adolescence with daily cigarette smoking in early adulthood: A longitudinal study among Finnish men

Aims: Swedish smokeless tobacco (snus) is a lower-risk tobacco product than cigarette smoking for individuals. However, the public health impact of snus use is less well studied. Critically, it is uncertain whether use of snus leads to the onset of smoking. This study aimed to investigate prospectively the association between snus experimentation in late adolescence and daily cigarette smoking in early adulthood among Finnish young men. Methods: Data were obtained from 1090 young men within the population-based FinnTwin12 cohort. At baseline (mean age 17 years), we assessed lifetime use of cigarettes and snus, plus other potential predictors of cigarette smoking. At follow-up (mean age 24 years), participants were categorized according to their current smoking status. The final analyses were conducted among 375 young men who were never smokers at baseline with adequate data on follow-up smoking status and other potential predictors of cigarette smoking. Results: Age-adjusted logistic regressions showed an increased risk of becoming a daily smoker at follow-up among those participants who had at least tried snus but had never smoked cigarettes at baseline (odds ratio (OR) 6.48, 95% confidence interval (CI) 2.02-20.7), compared with those who had never used snus. When additionally adjusted for monthly alcohol intoxication, maternal smoking, and peer drug use, the association between snus experimentation and later daily cigarette smoking was attenuated, but remained significant (OR 3.94, 95% CI 1.22-12.7). Conclusions: Our data support the proposition that snus experimentation during late adolescence is longitudinally associated with daily cigarette smoking in early adulthood. Although a causal association cannot be inferred with certainty, snus experimentation might constitute an indicator of the propensity to proceed to regular snus use and initiation of use of other tobacco or nicotine products.

Effectiveness of traditional lectures and case methods in Swedish general practitioners' continuing medical education about COPD: a cluster randomised controlled trial

OBJECTIVES

To study the effects of continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) by comparing two commonly used CME methods with each other and no CME (reference group).

DESIGN

A pragmatic cluster randomised controlled trial with primary healthcare centres (PHCCs) as units of randomisation.

SETTING, PARTICIPANTS AND INTERVENTIONS

24 PHCCs in Stockholm County, Sweden, were randomised into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME seminars were given in a period of 3 months.

PRIMARY OUTCOME MEASURES

Changes in scores between baseline and 12 months on a 13-item questionnaire about evidence-based COPD management (0-2 points/question, maximum total score 26 points).

RESULTS

133 (52%) GPs completed the questionnaire both at baseline and 12 months. Both CM and TL resulted in small yet significantly higher total scores at 12 months than at baseline (CM, 10.34 vs 11.44; TL, 10.21 vs 10.91; p<0.05); there were few significant differences between these CME methods. At both baseline and 12 months, all three groups' scores were generally high on questions about smoking cessation support and low on those that measured spirometry interpretation skills, interprofessional care and management of multimorbidity.

CONCLUSIONS

Neither short CM nor short TL CME sessions substantially improve GPs' skills in managing COPD. It is justified to challenge the use of these common CME methods as a strategy for improving GPs' level of knowledge about management of COPD and other complex chronic diseases characterised by multimorbidity.

TRIAL REGISTRATION NUMBER

NCT02213809; Results.

Health behaviours as a predictor of quitting hazardous alcohol use in the Stockholm Public Health Cohort

Background

Adopting healthy behaviours may facilitate the transition from hazardous to non-hazardous use of alcohol, yet, longitudinal studies of health behaviours in relation to the cessation of hazardous alcohol use are rare. We addressed this question using data from a large population-based cohort of adults in Sweden (Stockholm Public Health Cohort).

Methods

Participants from two sub-cohorts (inception in 2002 and 2010), with follow-up until the year 2014 were included. Health behaviours (tobacco use, diet and physical activity) and alcohol use were self-reported in questionnaire-based surveys. Hazardous alcohol use was defined as either usual weekly consumption (2002 sub-cohort) or heavy occasional alcohol consumption (2010 sub-cohort). Baseline hazardous drinkers with complete data constituted the analytical sample (n = 8946). Logistic regression was used to calculate the Odds Ratios and their 95% confidence intervals of quitting hazardous alcohol use, with tobacco use, diet and physical activity as predictors of change.

Results

In the 2002 sub-cohort, 28% reported non-hazardous use sustained through two consecutive follow-up points. In the 2010 sub-cohort, 36% of the participants reported non-hazardous use of alcohol at follow-up. Favourable health behaviours at baseline (e.g. no tobacco use, sufficient fruit intake and physical activity) were associated with a 19% to 75% higher of odds quitting hazardous alcohol use. Further, favourable changes in diet and tobacco cessation were associated with non-hazardous alcohol use at follow-up.

Conclusions

As many as one-third of hazardous alcohol users may quit this drinking pattern in a medium-long term. Holding or achieving a healthy lifestyle may facilitate this transition.

Associations between snus use, body mass index and general health in a cross-sectional population-based sample of women

Background: In Norway, snus use among women has increased substantially over the last decade, particularly in younger age groups. Snus use is associated with increased morbidity among men, but few studies have addressed health consequences of snus use among women. Aim: To investigate the associations between body mass index (BMI) and female snus use, and between self-rated general health and female snus use. Methods: A nationally representative net sample of 13,756 women in Norway, aged 18–45 years, participated in a survey on lifestyle and health. Ordinal logistic regression was applied to address associations between snus use and BMI/general health, adjusting for age and lifestyle factors. Results: Compared to never users of snus, daily snus users had a lower likelihood of high BMI (OR: 0.83, 95% CI: 0.68–1.00), a higher likelihood of low BMI (OR: 1.63, 95% CI: 1.14–2.33), and a higher likelihood of poor/fair health (OR: 1.43, 95% CI: 1.08–1.90). Former and occasional snus users did not differ from never users in terms of BMI or general health in multiply adjusted models. Daily smokers had the highest likelihood of reporting poor/fair health (OR: 2.18, 95% CI: 1.8–2.63) relative to never smokers. Conclusions: Daily female snus use was associated with a lower likelihood of being overweight, and a higher likelihood of being underweight. Moreover, daily snus use was associated with a higher likelihood of worse general health. Former and occasional female snus use was not associated with BMI or general health.

Profiling of smokers and snuffers among young Finnish men - cross-sectional epidemiological study. Acta Odontol Scand 2017;75:577-583. [PMID: 28789581 DOI: 10.1080/00016357.2017.1361548]

OBJECTIVE

The purpose of this study was to get new information from several sources about the background factors of Finnish smokers, snuffers, and dual users. Profiles of young smokers and snuffers were investigated in association with restorative treatment need, oral hygiene, eating habits, physical activity, body mass index (BMI), psychological and socioeconomic factors.

MATERIAL AND METHODS

The study group comprised 3420 conscripts. The data were collected from four different sources: a health examination including an oral health screening, a computer-based questionnaire for investigating individual background factors, a psychological test assessing cognitive skills, and the Cooper test. Statistical analyses comprised cross tabulation and binary logistic regression modelling.

RESULTS

The odds for smoking were the greatest among those who had DT (Decayed teeth) > 0, used energy drinks or alcohol regularly, or whose parents were divorced. A score of ≥2900 m in the Cooper test, a higher physical exercise level, a higher own education level, and using sports drinks decreased the odds for smoking. The odds for snuffing were higher among those who ran >2500 m in the Cooper test, had a BMI of ≥25, used sports/energy drinks, or exercised regularly, and lower among those who achieved good results in the cognitive test. Using energy/sports drinks or alcohol was positively and a higher education level was negatively associated with dual use.

CONCLUSIONS

Along with increasing prevalence of snuffing, heterogeneity is likely among snuffers. Good cognitive skills may prevent from smoking and snuffing.

The Prognostic Value of Combined Smoking and Alcohol Consumption Habits for the Estimation of Cause-Specific Mortality in Middle-Age and Elderly Population: Results from a Long-Term Cohort Study in Lithuania

Aim

To evaluate the prognostic value of combined smoking and alcohol consumption habits for the estimation of cause-specific mortality risk in middle-age and elderly population.

Methods

The study presents data from the four surveys. A random sample of 6,729 subjects aged 35-64 years was selected for statistical analysis. During the follow-up of 31 years (1983-2014), there were 2,158 deaths from any cause. Multivariate Cox's proportional hazards models were used to estimate hazard ratios (HR) for all-cause mortality and Competing Risk Regression analysis was used to estimate subdistribution hazard risk (SHR) for cause-specific mortality.

Results

Smoking clearly increased the risk of all-cause mortality and mortality from cancer and cardiovascular disease (CVD), but alcohol use had little effect in men aged 35-64 years. However, heavy alcohol consumption (>14 units/week) increased the risk of all-cause mortality and mortality from external causes in the never-smokers men group who drank alcohol of 1-14 units/week (HR 2 = 1.57 and SHR 2 = 2.40, resp.).

Conclusions

The smoking habits and alcohol consumption are modifiable risk factors, and thus efforts to support abstinence from alcohol and smoking use should be a public health priority.

Smokeless tobacco (snus) use and colorectal cancer incidence and survival: Results from nine pooled cohorts

AIMS

Although smoking is considered to be an established risk factor for colorectal cancer, the current evidence on the association between smokeless tobacco and colorectal cancer is scant and inconclusive. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess this association.

METHODS

A total of 417,872 male participants from nine cohort studies across Sweden were followed up for incidence of colorectal cancer and death. Outcomes were ascertained through linkage to health registers. We used shared frailty models with random effects at the study level to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During 7,135,504 person-years of observation, 4170 men developed colorectal cancer. There was no clear association between snus use and colorectal cancer overall. Exclusive current snus users, however, had an increased risk of rectal cancer (HR 1.40: 95% CI 1.09, 1.79). There were no statistically significant associations between snus use and either all-cause or colorectal cancer-specific mortality after colorectal cancer diagnosis.

CONCLUSIONS

Our findings, from a large sample, do not support any strong relationships between snus use and colorectal cancer risk and survival among men. However, the observed increased risk of rectal cancer is noteworthy, and in merit of further attention.

Use of Swedish smokeless tobacco (snus) and the risk of Type 2 diabetes and latent autoimmune diabetes of adulthood (LADA)

AIMS

It has been suggested that moist snuff (snus), a smokeless tobacco product that is high in nicotine and widespread in Scandinavia, increases the risk of Type 2 diabetes. Previous studies are however few, contradictory and, with regard to autoimmune diabetes, lacking. Our aim was to study the association between snus use and the risk of Type 2 diabetes and latent autoimmune diabetes of adulthood (LADA).

METHOD

Analyses were based on incident cases (Type 2 diabetes, n = 724; LADA, n = 200) and population-based controls (n = 699) from a Swedish case-control study. Additional analyses were performed on cross-sectional data from the Norwegian HUNT study (n = 21 473) with 829 prevalent cases of Type 2 diabetes. Odds ratios (OR) were estimated adjusted for age, BMI family history of diabetes and smoking. Only men were included.

RESULTS

No association between snus use and Type 2 diabetes or LADA was seen in the Swedish data. For Type 2 diabetes, the OR for > 10 box-years was 1.00 [95% confidence interval (CI), 0.47 to 2.11] and for LADA 1.01 (95% CI, 0.45 to 2.29). Similarly, in HUNT, the OR for Type 2 diabetes in ever-users was estimated at 0.91 (95% CI, 0.75 to 1.10) and in heavy users at 0.92 (95% CI, 0.46 to 1.83).

CONCLUSION

The risk of Type 2 diabetes and LADA is unrelated to the use of snus, despite its high nicotine content. This opens the possibility of the increased risk of Type 2 diabetes seen in smokers may not be attributed to nicotine, but to other substances in tobacco smoke.

Smokeless tobacco use in Sweden and other 17 European countries

INTRODUCTION

The purpose of this study is to report prevalence and determinants of use of smokeless tobacco in a representative sample of men and women from Sweden, where Swedish snus sales are legal, and from 17 other European countries, where sales of smokeless tobacco are restricted.

METHODS

In 2010, a face-to-face survey including information on current smokeless tobacco use was conducted in a representative sample of around 1000 individuals aged ≥15 years per country in Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden.

RESULTS

In Sweden, the overall prevalence of smokeless tobacco use was 12.3% (20.7% in men, 3.5% in women). The corresponding estimate for other European countries combined was 1.1% (1.2% in men, 1.1% in women). Compared with never smokers, former smokers in Sweden were significantly more likely to use smokeless tobacco (odds ratio, OR: 2.67), whereas no difference in use was observed in other countries (OR: 1.04). Use of smokeless tobacco was similar among current smokers in Sweden (OR: 1.96) and in other countries (OR: 2.40) when contrasted to never smokers. In Sweden there were no differences in the number of cigarettes/day between smokers who also use smokeless tobacco (13.3 cigarettes/day) and exclusive cigarette smokers (12.9 cigarettes/day; P = 0.785).

CONCLUSIONS

Excluding Sweden, current oral tobacco use was not commonly reported in the European countries surveyed and was similarly rare both in men and in women. In Sweden, however, use of smokeless tobacco was about 10-fold higher than the rest of Europe and more prevalent in men than in women.

Use of snus, its association with smoking and alcohol consumption, and related attitudes among adolescents: the Finnish National School Health Promotion Study

Background

The relationship between the use of snus and lifestyle-related habits – especially in adolescence, when these behaviours begin and become established – is not widely studied. Our aim was to analyse associations between snus use and habits of and attitudes towards smoking and alcohol consumption among Finnish adolescents.

Methods

The study is a part of the National School Health Promotion Study in Finland. The study population consisted of a representative sample of Finnish adolescents (n = 183 226). A questionnaire enquired about pupils’ use of snus, habits of and attitudes towards smoking and alcohol consumption, as well as their (age, gender, school type) and their parents’ (education and smoking) background factors. Chi-square tests and logistic regression models served in the statistical analyses.

Results

Of the adolescents, 18 % had used snus (2 % daily, 16 % experimented) while 82 % never had. Snus use was more common among boys than girls (p < 0.05). Concerning smoking, 19 % were daily and 15 % occasional smokers. Regarding alcohol, 11 % consumed it weekly and 57 % monthly or less frequently. More than two thirds of the adolescents held positive attitudes towards smoking (71 %), and alcohol (67 %). Male gender (OR = 9.9; 95 % CI 9.4–10.4), current (OR = 32.8; 95 % CI 26.1–41.1) or former (OR = 10.1; 95 % CI 8.0–12.9) smoking, weekly consumption of alcohol (OR = 27.4; 95 % CI 21.0–35.8), positive attitude towards smoking (OR = 1.4; 95 % CI 1.3–1.6), and higher parental education (OR = 1.4; 95 % CI 1.3–1.4) associated significantly with adolescents’ current snus use, whereas parental smoking did not.

Conclusion

Current snus use among adolescents may signal an accumulation of other lifestyle-related risky behaviours such as current or past smoking and alcohol consumption as well as a positive attitude towards smoking. In addition to these possible co-existing health-related risk factors, health promotion activities should take into account gender and school differences in order to target preventive messages to youth more effectively.

Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway

INTRODUCTION

While smoking in Norway has become less prevalent, snus use has increased, including among women. The aims of this study were to describe female snus use and its correlates, and to contrast patterns of snus use and smoking.

METHODS

In 2011-2012, data on tobacco use, age, education, alcohol consumption, sexual behaviors, and physical activity were collected from a population based sample of 13 756 Norwegian women aged 18-45 years, using a self-administered questionnaire.

RESULTS

Ever-use prevalence of snus ranged from 29.6% to 4.5% among those aged 18-19 years and 40-45 years, respectively. In contrast, the corresponding figures for smoking were 24.1% and 44.1%. Among snus users, 54.1% and 22.8% of 18-19 and 40 to 45-year-olds had never smoked, respectively. Debut age for snus use increased markedly with age, and was higher than debut age for smoking. Female snus use was positively associated with intermediate education, alcohol consumption, number of sexual partners, and hard physical activity. Smoking was also positively associated with alcohol consumption and number of sexual partners, but negatively associated with physical activity and education.

CONCLUSION

While most snus users among older women were former or current smokers, this was not the case among younger women. Low snus debut age and extensive snus use among younger women suggest that measures to reduce snus use should be targeted at young adolescents. The correlates of female snus use and smoking were not identical, and were similar to those previously documented for men.

Smoking, alcohol use, socioeconomic background and oral health among young Finnish adults

OBJECTIVES

The aim of this study was to investigate the prevalence of smoking and alcohol use in association with dental caries experience and signs of periodontal disease in a Finnish male group born in the early 1990s. The impacts of health behaviour and socioeconomic factors were included in the analyses.

METHODS

Oral health of 8539 conscripts was screened in a cross-sectional study (DT, DMFT and CPI). They also answered a questionnaire covering their habits of smoking and alcohol use as well as other behaviours and background factors. The bleeding on probing index (BOP) was available on 6529 conscripts. Cross-tabulation together with a chi-squared test and generalized linear mixed models were used in the analyses. A mosaic figure was used to illustrate associations of smoking frequency, use of dental services and toothache.

RESULTS

Majority (80.9%) in the study group consumed alcohol at least once a month, and 39.4% were daily smokers. Smoking was statistically significantly associated with high caries experience and high bleeding values of gums. Consumption of alcohol was not associated with dental caries and periodontal disease. The high BOP value had the strongest association with infrequent tooth brushing and smoking. The participant's own education level was the main protective factor of oral health. The smokers used dental services more frequently compared to the non-smokers mostly for acute care.

CONCLUSIONS

Young men's health behaviour, especially of those with low education, does not promote oral health, which may indicate need for extensive healthcare services in the future. Health promotion should not be neglected.

Use of moist smokeless tobacco (snus) and the risk of development of alcohol dependence: a cohort study in a middle-aged population in Sweden

BACKGROUND

Convincing evidence shows that smoking is associated with alcohol dependence (AD) and a positive correlation between snus and alcohol consumption was previously shown in cross-sectional studies. We performed a longitudinal evaluation of the risk of snus users to develop AD.

METHODS

A cohort study in Västerbotten County, Sweden, linked individual data on socioeconomic situation and health survey data from 21,037 men and women (46.5% men). AD was defined by the CAGE questionnaire and evaluated at baseline 1991-1997 and again after 10 years. The risk of developing AD was assessed using logistic regression analysis and propensity score matching.

RESULTS

2370 men and 430 women used snus and were without AD at baseline. Over the 10-year period, 499 men and 257 women developed AD, among whom 191 and 26, respectively, were baseline snus users. The crude relative risks of AD for male and female snus users compared to non-users were 1.8 with 95% CI (1.5, 2.2) and 2.9 (2.0, 4.3), respectively. Adjusted logistic regression showed a positive dose-response relationship between snus use and risk of AD. Analyses involving propensity score matching revealed 33 and 17 new cases of AD in men and women, respectively, after 10 years given 1000 men and 1000 women without AD had been baseline snus users rather than non-users. Results for current, previous and never smokers were similar.

CONCLUSIONS

The use of snus is prospectively associated with an increased risk of AD with a dose-response relationship that is independent of smoking status.

Tobacco use pattern among a national firefighter cohort

INTRODUCTION

To date, there have been no large-scale, national epidemiological studies of tobacco use patterns among firefighters, particularly with a focus on smokeless tobacco (SLT) and dual use with cigarettes. While rates of firefighters' smoking are relatively low compared to the general population, SLT use typically is substantially higher than the populations they protect. In the current study, we systemically examine tobacco use, including SLT and dual use, and the health-related profiles of various tobacco use groups in a national sample of career firefighters.

METHODS

Data are from a national cohort study of career departments (N = 20) comprised of 947 male firefighters.

RESULTS

Among 947 participants, 197 (21%) were tobacco users, of which, 34.5% used cigarettes, 53.2% used SLT, and 12.2% used both cigarettes and SLT. Adjusted rates of smoking, SLT use, and dual use were 13.2%, 10.5%, and 12.2%, respectively. Tobacco users of all types were significantly younger and had served fewer years in fire service and were significantly more likely to engage in heavy and binge drinking, as well as more likely to show signs of depressive symptoms compared to nontobacco users.

CONCLUSIONS

Detailed information on tobacco use pattern will aid in better understanding what factors are contributing to the high rates of SLT and dual use among firefighters in order to guide and develop an appropriate treatment program for the fire service.

Evaluation of a brief counseling for tobacco cessation in dental clinics among Swedish smokers and snus users. A cluster randomized controlled trial (the FRITT study)

OBJECTIVE

The aim of this study is to assess the effectiveness of a very brief structured counseling for tobacco cessation in dentistry clinics.

METHOD

A cluster randomized trial was conducted in Sweden in 2012-2013. Twenty-seven dentistry clinics in two Swedish counties were randomized to provide either a structured brief advice based on the 5 A's model or usual care. Participants were 467 patients currently using tobacco daily (225 in the intervention group and 242 in usual care), of which 97% were retained at follow-up, six months after enrolment. Study outcomes were: 7-day abstinence (primary outcome); 3-month sustained abstinence; 50% reduction of the amount tobacco used; quit attempts lasting at least 24h.

RESULTS

Compared to usual care, brief counseling was not associated to statistically significant increase in the proportion abstinent from tobacco use after 6months. However, there was a statistically significant association with reduction of tobacco consumption (OR=2.07 95% CI 1.28-3.35). Changes in the expected direction for all outcomes were more frequent in the intervention than in the usual care group, and larger among exclusive snus users than among smokers.

CONCLUSIONS

Very brief and structured counseling in dentistry may achieve positive behavioral modifications among tobacco users, with significant reduction of tobacco consumption, particularly among smokeless tobacco users.

Association of smoking and snuffing with dental caries occurrence in a young male population in Finland: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the prevalence of smoking and snuffing habits in association with dental caries occurrence in a male cohort born in the early 1990s in Finland. The impact of health behaviours and factors related to the place of residence were included in analyses.

MATERIALS AND METHODS

Oral health of 8537 conscripts was screened in a cross-sectional study. In the same occasion they also answered a questionnaire covering their smoking and snuffing habits and other background factors. The residence-related factors were obtained from the Defence Forces' database. Cross-tabulation together with chi-squared test and generalized linear mixed models were used for analyses.

RESULTS

Almost forty per cent (39.4%) of the men reported smoking daily and 9.0% reported daily snuffing. Restorative treatment need of those who reported frequent smoking was more than 2-fold (mean DT = 2.22) compared to the non-smokers (mean DT = 1.07). Smoking was statistically significantly associated with other harmful health behaviours. The snuffers reported more snacking than the non-smokers, but were most frequent brushers. The result from the statistical modelling showed that smoking, low tooth brushing frequency, eating sweets and consuming energy drinks frequently were significantly associated with restorative treatment need.

CONCLUSION

In this cross-sectional study, association between smoking and dental caries was distinct. The high rate of restorative treatment need among smokers may be explained by their poor health behaviours. Dietary habits of the snuffers seem harmful too, but are compensated by good tooth brushing frequency.

Tobacco use among Norwegian adolescents: from cigarettes to snus

AIMS

To: (i) investigate the development of smoking and snus use among Norwegian adolescents, and (ii) describe the users in each group.

DESIGN

Two population-based surveys with identical procedures in 2002 (response rate 91.0%) and 2010 (response rate 84.3%).

SETTING

Norway.

PARTICIPANTS

A total of 6217 respondents, aged 16-17 years.

MEASUREMENTS

Data were collected on smoking and snus use, socio-demographic factors, school adjustment, social network, sport activities, alcohol and cannabis use and depression symptoms.

FINDINGS

Prevalence of daily smoking fell from 23.6% in 2002 to 6.8% in 2010 (P < 0.001), while the prevalence of daily snus use increased from 4.3 to 11.9% (P < 0.001). Dual daily use of cigarettes and snus remained at 1%. The relative proportion of non-daily smokers using snus increased steeply. Both snus users and smokers reported more adverse socio-economic backgrounds, less favourable school adjustment and higher levels of alcohol intoxication and cannabis use than non-users of tobacco. However, snus users were better adjusted to school and used cannabis less often than smokers.

CONCLUSIONS

Adolescent smoking prevalence has fallen dramatically in Norway, accompanied by a smaller increase in snus use. Young snus users in Norway have many of the same risk factors as smokers, but to a lesser degree.

Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival

BACKGROUND

Snus is a moist smokeless tobacco product with high nicotine content. Its use has a short-term effect on the cardiovascular system, but the relationship between snus use and stroke is unclear.

OBJECTIVE

The aim of this study was to assess the associations between use of snus and incidence of and survival after stroke, both overall and according to subtypes.

METHODS

Pooled analyses of eight Swedish prospective cohort studies were conducted, including 130 485 men who never smoked. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of incidence and death after diagnosis using Cox proportional hazard regression models and case fatality and survival using logistic regression and Kaplan-Meier methods, respectively.

RESULTS

No associations were observed between the use of snus and the risk of overall stroke (HR 1.04, 95% CI 0.92-1.17) or of any of the stroke subtypes. The odds ratio (OR) of 28-day case fatality was 1.42 (95% CI 0.99-2.04) amongst users of snus who had experienced a stroke, and the HR of death during the follow-up period was 1.32 (95% CI 1.08-1.61).

CONCLUSION

Use of snus was not associated with the risk of stroke. Hence, nicotine is unlikely to contribute importantly to the pathophysiology of stroke. However, case fatality was increased in snus users, compared with nonusers, but further studies are needed to determine any possible causal mechanisms.

Health risks related to dual use of cigarettes and snus - a systematic review

Reviews show that using snus (Swedish-type moist snuff) is much safer than smoking, with no increased risk from snus of cancer or circulatory disease yet demonstrated, but have not investigated possible health effects from dual use of cigarettes and snus. This review considers studies where health risks can be compared in dual users, those who only use snus or only smoke, and those who use neither product. The interaction RR, the ratio of RRs associated with snus use in smokers and in non-smokers, was used to test for special effects of dual use. Of 51 interaction RRs presented, only one (for gestational hypertension in a study based on the Swedish Medical Register) was significantly (p<0.05) above 1.0, and RRs below 1.0 were commoner, perhaps as cigarette consumption is lower in dual users than those who only smoke. Dual users more often initiate tobacco use with cigarettes than snus. Dual use is much commoner in adolescents than adults, possibly because many tobacco users try both products, eventually settling on one. Epidemiological evidence from various sources, though suffering from weaknesses, consistently suggests concomitant snus use increases smoking quit rates, and aligns with evidence from RCTs using snus to aid smoking cessation.

The effect of snus on alcohol-related cigarette administration in dependent and non-dependent smokers

INTRODUCTION

Alcohol has been found to increase tobacco smoking in both dependent daily smokers (DDS) and nondependent nondaily smokers (NNS), yet little attention has been directed toward examining how different treatments/products modify drinking-related smoking behavior.

METHODS

This study examined the acute effects of snus (4mg of nicotine) on alcohol-related smoking responses in 18 DDS and 17 NNS. During each double-blind session, participants were randomly assigned to receive one of the following combinations: alcohol and snus, alcohol and placebo snus, placebo alcohol and snus, or placebo alcohol and placebo snus. Participants consumed their assigned beverage before absorbing their session's product, and after 30min participants could self-administer puffs of their preferred brand of cigarette over a 60-minute period using a progressive ratio task.

RESULTS

Alcohol significantly increased tobacco craving (p<.001) and tended to decrease latency to start smoking (p=.021) but only among NNS. In contrast, snus tended to decrease the number of puffs earned and how hard DDS worked for puffs in both beverage conditions (ps≤.019) but it did not alter the smoking behavior of NNS. Craving was not significantly impacted by snus in either type of smoker.

DISCUSSION

These findings raise the possibility that different processes mediate alcohol and cigarette co-use in NNS and DDS and suggest that snus may be effective in reducing alcohol-related cigarette use in DDS specifically.

Factors associated with smokeless tobacco use and dual use among blue collar workers

OBJECTIVES

To examine demographic and substance use factors associated with exclusive smokeless tobacco use (SLT) and dual use of both cigarettes and SLT among blue-collar workers.

DESIGN AND SAMPLE

This cross-sectional study used data from the United States 2009 National Survey on Drug Use and Health. The sample (n = 5,392) was restricted to respondents who were classified as blue collar workers by self-report primary job title.

MEASURES

Various demographic variables, tobacco use and other substance use variables were examined.

RESULTS

Respondents in this blue collar sample were 87% male and 64% Non-Hispanic White. An estimated 9.5% (SE = 0.6) of respondents were current SLT users; 5.3% (SE = 0.4) were current exclusive SLT users, and 4.2% (SE = 0.4) were current dual users of both SLT and cigarettes. Factors related to exclusive SLT use were gender, marital status, age, race/ethnicity, type of blue-collar occupation, current binge drinking, and current marijuana use. Significant factors related to dual use were gender, marital status, age, race/ethnicity, type of blue-collar occupation, current cigar smoking, current binge drinking, and current illicit drug use.

CONCLUSIONS

Rates of SLT use and dual use are high among U.S. blue-collar workers, indicating a need for targeted, workplace cessation interventions. These interventions may also serve as a gateway for addressing other substance use behaviors in this population.

Snus use and cardiovascular risk factors in the general population: the HUNT3 study

BACKGROUND AND AIMS

Snus, a form of smokeless tobacco, is increasingly popular in its traditional Nordic markets, and was recently launched commercially in the United States. We examined the cross-sectional associations between snus use and cardiovascular risk factors, and compared them with the corresponding associations of smoking.

DESIGN

Cross-sectional study.

SETTING

The HUNT3 general population survey, Nord-Trøndelag, Norway (2006-08).

PARTICIPANTS

A general population sample of n = 25 163.

MEASUREMENTS

Measured triglyceride,- glucose- and high-density lipoprotein (HDL)-cholesterol levels, blood pressure and waist circumference, registry information on gender, age and education level, self-reported snus use, smoking, physical exercise and alcohol use.

FINDINGS

In age- and gender-adjusted linear regression analyses, extensive snus use was associated with larger waist circumference (b = 1.65, 95% CI = 0.86, 2.43) and higher systolic blood pressure (b = 2.58, 95% CI = 1.48, 3.68), but with higher rather than lower levels of HDL-cholesterol (b = 1.66, 95% CI = 0.79, 2.53). These three differences remained significant after additional adjustment for smoking, education level, physical exercise and alcohol use. Smokers had higher triglyceride and lower HDL-cholesterol than snus users, but lower systolic blood pressure.

CONCLUSIONS

After adjusting statistically for major confounding variables, Norwegians who use snus extensively have a mixed profile in terms of cardiovascular risk: slightly higher waist circumference and systolic blood pressure but also higher high-density lipoprotein-cholesterol.

Risk and protective factors of adolescent exclusive snus users compared to non-users of tobacco, exclusive smokers and dual users of snus and cigarettes

The use of snus is increasing in Norway. In this study we examined differences between adolescents who were exclusive snus users, and adolescent non-users, smokers and dual users of snus and cigarettes on a number of psychosocial factors, categorized as risk variables and protective variables associated with involvement in health compromising behavior. We applied separate logistic regression models, where exclusive snus users (n=740) were compared with non-users (n=904), smokers (n=219), and dual users (n=367). Compared to non-users, the group of exclusive snus users was associated with variables traditionally predicting health risk behavior, such as smoking friends (OR=1.74, SD 1.27-2.38) and truancy (OR=2.12, SD 1.65-2.78). Compared to smokers, exclusive snus users were related to variables traditionally associated with protection against involvement in health risk behavior, e.g. higher academic orientation (OR=1.66, SD 1.12-2.45). Associations with protective factors were also observed when exclusive snus users were compared with dual users. While the group of exclusive snus users was associated with a pattern of psychosocial risk compared to non-users, they showed a more conventional pattern when compared to smokers and dual users. The group of exclusive snus users may be described on a continuum varying from psychosocial risk factors to protective factors of risk involvement depending on the group of comparison.

Cohort profile: The Stockholm Public Health Cohort

The Stockholm Public Health Cohort was set up within the Stockholm County Council public health surveys to inform on determinants and consequences of significant contributors to the current burden of disease. Participants are 89 268 randomly selected individuals from the adult population of Stockholm County. Baseline surveys took place in 2002, 2006 and 2010 via self-administered questionnaires. So far, participants recruited in 2002 were re-surveyed twice, in 2007 and 2010, and those enrolled in 2006 were re-surveyed once, in 2010. Self-reported data are regularly supplemented by information from national and regional health data and administrative registers, for study participants and their relatives (including their offspring). Available data are extensive and include a wide array of health, lifestyle, perinatal, demographic, socio-economic and familial factors. The cohort is an international resource for epidemiological research, and the data available to the research community for specific studies obtained approval from the Stockholm Public Health Cohort Steering Committee and the Stockholm Regional Ethical Review Board.

Patterns of dual use of snus and cigarettes in a mature snus market

INTRODUCTION

We examine the prevalence of dual use of snus and cigarettes among Norwegian men by categorizing dual use into four categories according to the frequency of use of each product, considering the order of uptake of both products, and examining reasons for additional snus use. We compare dual users and exclusive cigarette smokers with respect to their smoking intensity, plans for quitting smoking, and future smoking identity.

METHODS

We used a data pool of six cross-sectional, national representative surveys conducted annually in the period 2005-2010 containing a total of 3,524 males aged 16-74.

RESULTS

6.8% of men had some kind of current concomitant use of snus and cigarettes--but only 1% reported a daily consumption of both products. The most typical pattern of dual use was a combination where daily use of one product was paired with occasional use of the other. Dual users consumed significantly fewer cigarettes per week (56.6; n = 226; SD, 53.82) than smokers who had either quit snus (79.6; n = 108; SD, 61.47) or single smokers with no history of snus use (80.2; n = 621; SD, 55.86). Only 24% with a history of dual use reported snus to be their first tobacco product, but the proportion who had initiated tobacco use with snus increased significantly with younger age. Among dual users with daily intake of snus, a majority of 53.6% reported that the purpose of their snus use was to quit smoking. A higher proportion of dual users (74.4%; 95% CI, 68.8-80.0; n = 235) than exclusive smokers (61.3%; 95% CI, 57.6-65.0; n = 658) reported that they most definitely or probably would be totally smoke-free 5 years into the future.

CONCLUSIONS

In the mature snus market of Norway, the magnitude of dual use of cigarettes and snus is relatively small. Dual users consume fewer cigarettes, and a higher proportion portray themselves as smoke-free in the future than do exclusive cigarette smokers.

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

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

Socioeconomic position and education in patients with coeliac disease

BACKGROUND AND AIM

Socioeconomic position and education are strongly associated with several chronic diseases, but their relation to coeliac disease is unclear. We examined educational level and socioeconomic position in patients with coeliac disease.

METHODS

We identified 29,096 patients with coeliac disease through biopsy reports (defined as Marsh 3: villous atrophy) from all Swedish pathology departments (n=28). Age- and sex-matched controls were randomly sampled from the Swedish Total Population Register (n=145,090). Data on level of education and socioeconomic position were obtained from the Swedish Education Register and the Occupational Register. We calculated odds ratios for the risk of having coeliac disease based on socioeconomic position according to the European Socioeconomic Classification (9 levels) and education.

RESULTS

Compared to individuals with high socioeconomic position (level 1 of 9) coeliac disease was less common in the lowest socioeconomic stratum (routine occupations=level 9 of 9: adjusted odds ratio=0.89; 95% confidence interval=0.84-0.94) but not less common in individuals with moderately low socioeconomic position: (level 7/9: adjusted odds ratio=0.96; 95% confidence interval=0.91-1.02; and level 8/9: adjusted odds ratio=0.99; 95% confidence interval=0.93-1.05). Coeliac disease was not associated with educational level.

CONCLUSIONS

In conclusion, diagnosed coeliac disease was slightly less common in individuals with low socioeconomic position but not associated with educational level. Coeliac disease may be unrecognised in individuals of low socioeconomic position.

Smokeless tobacco use among operating engineers

Workers in blue collar occupations have been shown to have higher rates of smokeless tobacco (ST) use compared to other occupational groups. Guided by the Health Promotion Model, the purpose of this study was to understand various factors that predict ST use in Operating Engineers. A cross-sectional design was used to determine variables related to ST use among Operating Engineers. Engineers (N = 498) were recruited during their 3-day apprentice certification course to participate in the study. Logistic regression was used to assess the associations between personal, psychological and behavioral characteristics associated with ST use. Past month ST use was reported among 13% of operating engineers surveyed. Multivariate analysis showed that younger age and lower rates of past month cigarette use were significantly associated with ST use, while higher rates of problem drinking were marginally associated with ST use. Operating Engineers are at high risk for using ST products with rates in this sample well over the national average. Work site interventions, which have shown promise in other studies, may be useful in decreasing ST use among this population.

Alcohol consumption and risk of pre-diabetes and type 2 diabetes development in a Swedish population

AIMS

Alcohol is a potential risk factor of Type 2 diabetes. However, more detailed information on effects of alcohol types and early phases of Type 2 diabetes development seems warranted. The aim of this study was to investigate the influence of alcohol consumption and specific alcoholic beverages on the risk of developing pre-diabetes and Type 2 diabetes in middle-aged Swedish men and women.

METHODS

Subjects, who at baseline had normal glucose tolerance (2070 men and 3058 women) or pre-diabetes (70 men and 41 women), aged 35-56 years, were evaluated in this cohort study. Logistic regression was performed to estimate the risk [odds ratio (OR) and 95% confidence interval (CI)] to develop pre-diabetes and Type 2 diabetes at 8-10 years follow-up, in relation to self-reported alcohol intake at baseline. Adjustment was performed for several risk factors.

RESULTS

Total alcohol consumption and binge drinking increased the risk of pre-diabetes and Type 2 diabetes in men (OR 1.42, 95% CI 1.00-2.03 and OR 1.67, 95% CI 1.11-2.50, respectively), while low consumption decreased diabetes risk in women (OR 0.41, 95% CI 0.22-0.79). Men showed higher risk of pre-diabetes with high beer consumption (OR 1.84, 95% CI 1.13-3.01) and of Type 2 diabetes with high consumption of spirits (OR 2.03, 95% CI 1.27-3.24). Women showed a reduced risk of pre-diabetes with high wine intake (OR 0.66, 95% CI 0.43-0.99) and of Type 2 diabetes with medium intake of both wine and spirits (OR 0.46, 95% CI 0.24-0.88 and OR 0.55, 95% CI 0.31-0.97, respectively), whereas high consumption of spirits increased the pre-diabetes risk(OR 2.41, 95% CI 1.47-3.96).

CONCLUSION

High alcohol consumption increases the risk of abnormal glucose regulation in men. In women the associations are more complex: decreased risk with low or medium intake and increased risk with high alcohol intake.

Sports activity and the use of cigarettes and snus among young males in Finland in 1999-2010

BACKGROUND

Studies of the relationship between sports activity and smoking among adolescents and young adults report contradictory results. We examined the association between sports activity (intensity and type of sport) and the current use of snus (Swedish snuff), cigarette smoking, and the combined use of cigarettes and snus (dual use) among young males in Finland.

METHODS

Data were collected from 16,746 male conscripts who completed a survey during the first days of their conscription during the years 1999-2010 (median age 19 years, response rate 95%). Main outcome measures were self-reported daily/occasional use of snus, cigarette smoking, and dual use. The association between sports activity, type of sport, and several sociodemographic background variables was assessed using logistic regression analysis.

RESULTS

Over the study period (1999-2010), the prevalence of cigarette smoking decreased from 42% to 34%, while snus use increased from 5% to 12%, and dual use increased from 7% to 13% (p < 0.001). Compared with no physical activity, regular competitive sports activity (defined as high-intensity sports activity) was positively associated with use of snus (odds ratio [OR] 10.2; 95% confidence interval [CI]: 7.8-13.5) and negatively with cigarette smoking (OR 0.2; 95% CI: 0.1-0.3). When stratified by type of sport in multivariate models, ice hockey was most strongly associated with snus use (OR 1.6; 95% CI: 1.4-1.9) and dual use (OR 2.0; 95% CI 1.8-2.3) compared with those not playing ice-hockey, followed by other team sports for snus use (OR 1.5; 95% CI: 1.3-1.8) and dual use (OR 1.8; 95% CI: 1.6-2.0) compared with those not participating in other team-sports.

CONCLUSIONS

Our results show a clear association between snus use and intensity and type of training. Team sports were associated with increased use of snus and dual use compared with no participation in team sports. These findings should be acknowledged when planning and implementing preventive strategies.

Who is using snus? - Time trends, socioeconomic and geographic characteristics of snus users in the ageing Swedish population

BACKGROUND

The prevalence of smoking in Sweden has decreased in recent decades, and is now among the lowest in the world. During the same period, the use of Swedish moist oral snuff, a smokeless tobacco called snus, has increased. Few studies have evaluated time trends of the socioeconomic and geographic characteristics of snus users in Sweden. This paper contributes to filling that gap.

METHODS

This study utilized the Linnaeus Database, which links national registers with comprehensive individual data on socioeconomic status (SES) to health data from a large ongoing health survey, the Västerbotten Intervention Programme (VIP). The VIP targets the entire middle-aged population of Västerbotten county at ages 40, 50 and 60 years with yearly cross-sectional surveys including self-reported data on tobacco habits. Time trends of snus use among 92,563 VIP-participants across different areas of residence and smoking groups were investigated graphically. Logistic regression was performed to estimate the associations between SES and geographical variables and current use versus non-use of snus.

RESULTS

Overall, in parallel to decreasing smoking, the increasing trend of snus use in this middle-aged population continues, particularly in 40-year-olds. In both genders, the highest prevalence of snus use was observed among previous smokers. The prevalence of snus use also increased over time among smokers, and was consistently higher compared to those who had never smoked. Among males - both those who had never smoked and previous smokers - low education (OR 1.21, 95%CI 1.06-1.40 and OR 1.28, 95%CI 1.14-1.43), living alone (OR 1.16, 95%CI 1.07-1.27 and OR 1.13, 95%ci 1.04-1.23), low income and living in rural areas was associated with using snus, while this was not seen among male current smokers. Among women, living alone was associated with using snus irrespective of smoking habits. Among female smokers, the OR for snus use increased with higher education.

CONCLUSIONS

A disadvantaged social profile and also higher prevalence in rural areas is observed among male snus users who had never smoked or were previous smokers. Among male smokers there was no association between SES and use of snus. The prevalence of snus use among women is increasing, but is still considerably lower than that of men. The association between snus and SES characteristics is less pronounced among women, although snus is clearly linked to living alone. These patterns should be taken into consideration in tobacco control policies.