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Cited by 0Smoking Behavior and CessationGlobal Public Health Policies and EpidemiologyOral Health Pathology and Treatment

Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review

Open access
Kopa-Stojak, Paulina Natalia, Pawliczak, Rafal·2026·Exposure and Health
DOI 10.1007/s12403-026-00812-w
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Abstract

This work attempts to summarize current knowledge about the health effects associated with the use of snus and TF-ONPs. The literature search was performed in July 2026 in Pub Med, EMBASE, Scopus and the Cochrane Database of Systematic Reviews. There was an increase in blood pressure, heart rate and presence of oral mucosal changes among snus and TF-ONPs users. Switching to such products helped to reduce the number of cigarettes smoked per day, urges to smoking and increased the odds of quitting. Using snus was associated with an increased risk of asthma, atrial fibrillation, hypertension, heart failure, stroke, diabetes type 2 and metabolic disorder. There was a weak association between using snus and schizophrenia and non-affective disorders and an increased risk of pancreatic and rectal cancer among snus users. Finally, maternal snus usage increased the risk of pregnancy complications, intellectual disability or giving birth to a newborn small for gestational age of offsprings and asthma in preschool age. Current literature confirmed negative health consequences associated with regular use of snus. However, the findings are based on the studies performed mostly on male participants living in Scandinavia. Moreover, there is currently too little data to clearly determine the health effects of using TF-ONPs. Therefore, long-term randomized controlled trials involving individuals (males and females) exclusively using TF-ONPs, as well as snus (from different manufacturers and composition) should be performed in the future. Trial registration : The study protocol of this systematic review was registered in International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD420251062250.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review of 66 studies finds that regular snus use is associated with negative cardiovascular, metabolic, oral, respiratory, and pregnancy-related outcomes, while evidence on tobacco-free oral nicotine pouches (TF-ONPs) remains too limited to characterize their health effects. Both product types increased blood pressure, heart rate, and oral mucosal changes, and switching to either reduced cigarettes per day and increased odds of quitting.

Key findings

  • Among 66 included studies (40 conducted in Sweden; 54 on snus, 15 on ONPs), snus use was associated with increased blood pressure, heart rate, and oral mucosal changes, plus increased risk of asthma, atrial fibrillation, hypertension, heart failure, stroke, type 2 diabetes, and metabolic disorder; e.g., hypertension mortality aHR = 1.64 (95% CI 1.36–1.98) and heart failure mortality aHR = 1.75 (95% CI 1.17–2.62) in never-smoking middle-aged men (Loennberg et al. 2026).
  • Cancer findings were mixed: increased pancreatic cancer risk (RR = 2.0; 95% CI 1.2–3.3) and rectal cancer risk in exclusive current snus users (HR = 1.40; 95% CI 1.09–1.79), but no association with oral, lung, or colorectal cancer; snus was inversely associated with Parkinson's disease (pHR = 0.41; 95% CI 0.28–0.61).
  • Maternal snus use during pregnancy increased risk of stillbirth (aOR = 1.6; 95% CI 1.1–2.3), preterm birth, and offspring intellectual disability (OR = 1.28; 95% CI 1.06–1.52).
  • Switching to snus or ONPs reduced cigarettes per day and increased odds of quitting (e.g., complete switching to snus reduced CPD from 15 to 1.5, p < 0.001; ONP switching reduced CPD from 15.0 to 8.3, p < 0.01), though ONP data came from far fewer studies.

Methods

  • Systematic review conducted per PRISMA guidelines and registered in PROSPERO (CRD420251062250); literature searched up to July 25, 2026 in PubMed, EMBASE, Scopus, and the Cochrane Database of Systematic Reviews without time limits.
  • From 2,215 identified records, duplicates reduced the set to 1,241 screened by title/abstract, 102 assessed for eligibility, and 66 human studies included (controlled trials, cross-sectional, case-control, cohort, observational, prospective); studies on poly-users, general smokeless tobacco without product division, or biomarkers of exposure/hazard were excluded.
  • Data were synthesized narratively; study quality was assessed with NIH Study Quality Assessment Tools and risk of bias with CLARITY, NOS-xs, and JBI tools.

Limitations

  • Stated by the authors: many studies were conducted exclusively in men, limiting generalizability; limited TF-ONP data prevented detailed summary; many studies relied on self-reported tobacco use (response bias); heterogeneity of variables prevented meta-analysis; most studies came from Scandinavia and used observational/case-control/cross-sectional designs that cannot establish causality; brands, nicotine doses, flavors, exposure times, and demographics varied widely; and study quality was not always satisfactory.
  • Evident from the text: the review itself reports no pooled effect estimates, and several findings rest on single studies or small samples (e.g., ONP cardiovascular findings from Renard et al. with n = 30; several ONP oral-health studies with n = 23–272).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s12403-026-00812-w

Cites

212 of 212 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

24 of 180 cited sources checked · 16 supported · 2 flagged · accuracy not yet measured

  • Findingcitation
    § Additional information

    0.2% decline in heart rate for Nordic Spirit 11.2 mg ONP 30 min post-exposure.

    “0.2% decline in HRT for Nordic Spirit 11.2 mg ONP 30 min post-exposure”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Renard et al. 2025 source

      The Results (Physiological effects) report a 0.2% increase in pulse rate for Nordic Spirit 11.2 mg, not a decline. This measurement was taken 30 minutes after the end of product use. (LLM, conf=0.93)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Findingcitation
    § Additional information

    27.8% of ONPs users reported frequent coughing or wheezing.

    “27.8% of ONPs users reported frequent coughing or wheezing”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Alkharaan et al. 2025 source

      The Discussion reports frequent coughing in 18.6% of ONP users, not 27.8%. The Methods list frequent coughing among the surveyed symptoms but do not identify a combined coughing-or-wheezing measure. (LLM, conf=0.86)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation
    § Introduction

    There is only a limited number of data on the long-term effect of snus and TF-ONPs on users' health.

    “Furthermore, there is only a limited number of data on their long-term effect on their user's health (Rungraungrayabkul et al. 2024).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Rungraungrayabkul et al. 2024 source

      The Background says evidence on nicotine pouches is insufficient and calls for research into their short- and long-term oral-health effects. The Discussion says the three included studies could not definitively determine their oral-health impact. This supports limited evidence for tobacco-free nicotine pouches, but the review does not establish the same claim about snus or users’ overall long-term health. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Findingcitation
    § Chronic

    There is a positive association between snus use and the risk of colon cancer (HR = 1.08; 95% CI: 0.91-1.29).

    “A positive association between snus use and the risk of colon cancer (HR = 1.08; 95% CI: 0.91-1.29)(Nordenvall et al. 2011)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Nordenvall et al. 2011 source
  • Findingcitation
    § Chronic

    Among participants using snus for 24 weeks, there is a higher reduction in average number of smoked cigarettes per day (≥ 75%) (9.5%; p < 0.01) compared to the placebo group (2.5%).

    “Higher reduction in average number of smoked cigarettes per day (≥ 75%) among participants who used snus for 24 weeks (9.5%; p < 0.01) compared to placebo group (2.5% for 24 weeks)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Joksić et al. 2011 source
  • Classified as probably not a substantial claim. 30
  • May combine two claims. 79
  • The quote only partly states this claim. 2

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation
    § Risk of Bias Assessment of Included Studies

    Risk of bias for cross-sectional studies was assessed by the NOS-xs Tool.

    “Risk of bias for crosssectional studies was assessed by NOS-xs Tool (adaptation of the Newcastle-Ottawa Scale) (Carra et al. 2025).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Carra et al. 2025 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation
    § Eligibility Criteria

    This systematic review was carried out in accordance with PRISMA guidelines and registered in PROSPERO with registration number CRD420251062250.

    “This systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al. 2021) and registered in International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD420251062250.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Page et al. 2021 source

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Using snus is positively associated with increased odds of asthma (aOR = 1.49; 95% CI: 1.20-1.85) and asthma symptoms, chronic bronchitis, and chronic rhinosinusitis.

    “positive association between using snus and increased odds of asthma (aOR = 1.49; 95% CI: 1.20-1.85)and asthma symptoms: wheezing (aOR = 1.56; 95% CI: 1.32-1.84),wheezing and breathlessness (aOR = 1.38; 95% CI: 1.12-1.69),wheezing without having a cold (aOR = 1.48; 95% CI: 1.21-1.80),night-time chest tightness (aOR = 1.41; 95% CI: 1.16-1.71),night-time attacks of breathlessness (aOR = 1.39; 95% CI”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Gudnadóttir et al. 2017 source

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Among ONP users, 24.6% reported throat symptoms and 18.6% reported frequent cough.

    “24.6% of ONP users reported throat symptoms and 18.6% of them frequent cough (Alkharaan et al. 2025).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Alkharaan et al. 2025 source

  • May combine two claims.

    Findingcitation
    § Norberg et al.

    Current snus use compared to never-use is associated with increased odds of weight gain (OR = 1.31, 95% CI: 1.04-1.65) and incident obesity (OR = 1.93, 95% CI: 1.13-3.30).

    “current snus use compared to never-use was associated with increased odds of weight gain (OR = 1.31, 95% CI: 1.04-1.65)and incident obesity (OR = 1.93, 95% CI: 1.13-3.30)(Hansson et al. 2011).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hansson et al. 2011 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation
    § Additional information

    11.6% of ONPs users reported frequent colds or flu.

    “11.6% of ONPs users reported frequent colds or flu”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Alkharaan et al. 2025 source

      The Results section on ONP-associated symptoms reports abdominal symptoms and the proportion reporting no symptoms, but does not report frequent colds or flu. A search for “frequent colds or flu” and “11.6%” found no passage substantiating the claimed symptom or percentage. (LLM, conf=0.72)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingnone given
    § Abstract

    There was an increase in blood pressure, heart rate and presence of oral mucosal changes among snus and TF-ONPs users.

    “There was an increase in blood pressure, heart rate and presence of oral mucosal changes among snus and TF-ONPs users.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given
    § Abstract

    Switching to snus or TF-ONPs reduces the number of cigarettes smoked per day, urges to smoking, and increases the odds of quitting.

    “Switching to such products helped to reduce the number of cigarettes smoked per day, urges to smoking and increased the odds of quitting.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation
    § Hergens et al.

    Snus users have lower desire and intention to smoke and anticipation of relief from negative affect compared to baseline, but higher compared to conventional cigarette smokers.

    “Lower desire and intention to smoke and anticipation of relief from negative affect in snus users compared to baseline, but higher compared to CCs (Liu et al. 2022)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Liu et al. 2022 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data
    § Study Characteristics

    Among the 66 included studies, 40 were located in Sweden, 8 in the USA, 6 in Norway, 1 in Latvia, 1 in Hungary, 1 in Serbia, 1 in New Zealand, 3 in Saudi Arabia, and 5 were international.

    “Among 66 studies, 40 were located in Sweden”
    • Also stated in: § Study Characteristics · plain
      “8 in USA”
    • Also stated in: § Study Characteristics · plain
      “6 in Norway”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Among the included case-control studies, the NIH Quality Assessment Tool scores ranged from six to eight (two studies scored 8, one scored 7, one scored 6), classified as fair quality.

    “the score of the NIH Quality Assessment Tool used for each of the case-control study ranged between six to eight (two studies scored at eight, one study at seven and one at six), which is classified as fair quality of studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Fifteen of the included studies investigated ONPs health effects.

    “and only 15 of them ONPs health effects (Thornley et al. 2009;Rensch et al. 2021;Liu et al. 2022Liu et al. , 2025;;Keller-Hamilton et al. 2024;Avila et al. 2024;McDowell et al. 2024;Al-Nafisi et al.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Among the included observational, cohort and cross-sectional studies, the NIH Quality Assessment Tool scores ranged from five to nine (five studies scored 9, thirteen scored 8, seventeen scored 7, thirteen scored 6, three scored 5), classified as fair quality.

    “When the case comes to observational, cohort and cross-sectional studies, the NIH Quality Assessment Tool used for each of the study assessed the score range between five to nine (five studies scored at 9, thirteen at 8, seventeen at 7, thirteen at 6 and three at 5), which is classified as fair quality of the studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

    Findingnone given
    § Quality of the Studies

    In no included case-control study were the assessors blinded to the case or control status of participants.

    “In any study the assessors were blinded to the case or control status of participants.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingcitation
    § Hergens et al.

    Smoking quit ratio is significantly higher for daily snus users (range: 54.8%-89.7%) and former snus users (range: 31.1%-85.7%) compared to occasional snus users.

    “Smoking quit ratio was significantly higher for daily (range: 54.8%-89.7%)and former (range: 31.1%-85.7%)snus users”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lund et al. 2011 source

      Checked before — its earlier verdict is held back until a new check runs.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Five of the included articles investigated the association between using snus/ONPs and the risk of cancer development.

    “5 articles investigated association between using snus/ONPs and the risk of cancer development (Luo et al. 2007;Nordenvall et al. 2011;Araghi et al. 2017b;2017a, 2021).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Fourteen of the included studies investigated gastrointestinal and metabolic health effects.

    “14 gastrointestinal and metabolic (Eliasson et al. 2004;Norberg et al. 2006;Hansson et al. 2011;Östenson et al. 2012;Øverland et al. 2013;Lie et al. 2017;Carlsson et al. 2017;Rasouli et al. 2017;Byhamre et al. 2017;Titova et al. 2021Titova et al. , 2023”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Chronic

    Among women who use snus during pregnancy, there are increased risks of very preterm (> 32 weeks) birth (aOR = 1.38; 95% CI: 1.04-1.83) and moderately preterm (32-36 weeks) birth (aOR = 1.25; 95% CI: 1.12-1.40).

    “Increased risks of very (> 32 weeks)(aOR = 1.38; 95% CI: 1.04-1.83)and moderately (32-36 weeks) (aOR = 1.25; 95% CI: 1.12-1.40)preterm birth among women who use snus during pregnancy (Wikström et al. 2010a)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wikström et al. 2010a source

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Three of the included randomized trials were open-label (no blinding), and only five trials explained the randomization and allocation procedure in detail.

    “There were three open-label randomized trials (no blinding) and only five trials explaining randomization and allocation procedure in detail.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Chronic

    Among women who use snus during pregnancy, there is an increased risk of stillbirth (aOR = 1.6; 95% CI: 1.1-2.3), especially preterm (< 37 weeks) stillbirth (aOR = 2.1; 95% CI: 1.3-3.4).

    “Increased risk of stillbirth (aOR = 1.6; 95%CI: 1.1-2.3),especially preterm (< 37 weeks) stillbirth (aOR = 2.1; 95% CI:1.3-3.4) among women who use snus during pregnancy (Wikström et al. 2010b)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wikström et al. 2010b source

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    With the exception of one study, all included observational, cohort and cross-sectional studies were based on self-reported data regarding snus/ONPs use, and few on self-reported outcomes.

    “With the exception of one study, all were based on selfreported data regarding snus/ONPs use and few of them on self-reported outcomes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Only few included observational, cohort and cross-sectional studies measured snus/ONPs use a number of times during the procedure (e.g., at baseline and follow-up), and only few reported the percentage of participants lost to follow-up.

    “only few studies measured snus/ONPs use a number of times during the procedure (i.e. at baseline and follow-up) and only few of them reported percentage of participants loss of follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § Quality of the Studies

    Only one included case-control study justified sample size, and one study did not adjust statistically for key potential confounding variables in the analyses.

    “only one study justified sample size and one study did not adjust statistically key potential confounding variables in the analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § Chronic

    79% of snus users reported hyperkeratosis, and the odds of hyperkeratosis increase with the number of snus used per day (OR = 18.5 for 5-10 per day; OR = 2.95 for 11-15 per day; OR = 5.21 for 16-20 per day; p = 0.0007).

    “79% of snus users reported hyperkeratosis; Odds of hyperkeratosis increases with the number of snus use (OR = 18.5 for 5-10 snus per day; OR = 2.95 for 11-15 snus per day; OR = 5.21 for 16-20 snus per day; p = 0.0007)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Cardiovascular System

    Acute snus exposure in snus users compared to non-users increases systolic blood pressure, diastolic blood pressure, and heart rate 30 minutes post exposure.

    “observed an increase in systolic blood pressure (SBP) (115 ± 9 vs. 109.2± 6.8 mmHg; p < 0.001 for females; 124.5 ± 10 vs. 120.5 ± 9 mmHg; p < 0.05 for males), diastolic blood pressure (DBP) (72.1 ± 6.9 vs. 67.3± 6.3 mmHg; p < 0.001 for females) and heart rate (HRT) (66.7 ± 11.2 vs. 57.8± 9.8 bpm; p < 0.001 for females) in snus users compared to non-users 30 min post exposure.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Antoniewicz et al. 2018 source

      Checked before — its earlier verdict is held back until a new check runs.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Sixteen of the included studies investigated cardiovascular health effects.

    “Furthermore, 16 studies investigated cardiovascular (Haglund et al. 2007;Hergens et al. 2007Hergens et al. , 2008Hergens et al. , 2014;;Hansson et al. 2009Hansson et al. , 2012Hansson et al. , 2014;;Arefalk et al. 2012;Øverland et al. 2013;Antoniewicz et al. 2014Antoniewicz et al. , 2018Antoniewicz et al. , 2022;;Titova et al. 2021;Renard et al. 2025;Loennberg et al. 2026;Aldali 2026)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Selection

    Sixty-six studies were included in this systematic review.

    “Finally, n = 66 studies were included in this systematic review.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    No included observational, cohort or cross-sectional study justified sample size in detail, and none reported blinding of the outcome and exposure status of participants to the assessors.

    “no study justified sample size in detail, as well as none of them reported blinding of the outcome and exposure status of participants to the assessors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Fifty-four studies included in this systematic review investigated health effects of snus.

    “Moreover, 54 studies included in this systematic review investigated health effects of snus”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Five of the included articles discussed consequences of using snus/ONPs during pregnancy.

    “5 articles discussed consequences of using snus/ONPs during pregnancy (Wikström et al. 2010a;2010b;Lundholm et al. 2020;Madley-Dowd et al. 2022;López-Cervantes et al. 2024a).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Chronic

    Complete and partial switching to snus increases snus per day use and increases smoke-free days (p = 0.02 and p < 0.001, respectively).

    “Increase in snus per day (SPD) use after complete and partial switching to snus (from 0 to 7.1 for complete and from 0 to 4.6 for partial Switching to snus; p = 0.02), as well as more smoke-free days (median = 14.5 for complete switching to snus, median = 0 for partial switching to snus and continuing CC smoking; p < 0.001)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Meier et al. 2019 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Chronic

    Leathery white lesions, round white lesions, dot-like lesions and white linear lesions occur in snus users.

    “Leathery white lesions, round, white lesions, dot-like lesions and white, linear lesions in snus users (Miluna et al. 2022)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Miluna et al. 2022 source

      Checked before — its earlier verdict is held back until a new check runs.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Selection

    The number of articles was reduced to 102, which were assessed for eligibility.

    “Then, the number of articles was reduced to 102, which were assessed for eligibility.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Characteristics

    Ten of the included articles addressed the potential abuse of snus/ONPs and their effect on smoking reduction and cessation.

    “we included 10 articles on the potential abuse of snus/ONPs and their effect on smoking reduction and cessation (Thornley et al. 2009;Lund et al. 2011;Joksić et al. 2011;Meier et al. 2019;Rensch et al. 2021;Liu et al. 2022;Keller-Hamilton et al. 2024;Avila et al. 2024;McDowell et al. 2024;Lee et al. 2026).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given
    § Chronic

    32% of snus users reported mucosal erythema.

    “32% of snus users reported mucosal erythema”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Cardiovascular System

    Acute exposure to snus compared to placebo significantly increases systolic blood pressure and heart rate.

    “acute exposure to snus compared to placebo significantly increased SBP (+ 8.1 ± 11 mmHg vs. +1.7 ± 11 mmHg; p = 0.002) and HRT (+ 9.3 ± 13 bpm vs. +2.3± 12 bpm; p < 0.001).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Antoniewicz et al. 2014 source

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Not all included observational, cohort and cross-sectional studies examined different levels of exposure as related to the outcome and measured key potential confounding variables and adjusted statistics for their impact on the exposure-outcome relationship.

    “not all studies examined different levels of exposure as related to the outcome and measured key potential confounding variables and adjusted statistics for their impact on the relationship between exposure and outcome.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Only four included studies calculated and justified sample sizes in detail, and the overall drop-out rate in four studies was above 20%.

    “only four studies calculate and justify sample sizes in detail (most of them based on the sample size from previous studies) and overall drop-out rate in four studies was above 20%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Quality of the Studies

    Among the included randomized controlled trials, the NIH Quality Assessment Tool scores ranged from six to twelve (two studies scored 12, four scored 10, five scored 9, one scored 6), classified as fair to good quality.

    “In case of randomized controlled trials, the NIH Quality Assessment Tool used for each of the study assessed the score range between six to twelve (two studies scored at 12, four at 10, five at 9 and one at 6), which is classified as fair and good quality of the studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Study Selection

    The literature search identified 2,215 potential articles.

    “The literature search allowed to identify n = 2,215 potential articles (including n = 330 in Pub Med, n = 638 in Scopus, n = 1,078 in EMBASE and n = 169 in Cochrane database).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Chronic

    There is no association between snus use and odds of diabetes type 2 in a Swedish study (OR = 1.00, 95% CI: 0.47-2.11) and in a Norwegian study (OR = 0.91; 95% CI: 0.75-1.10 for ever users; OR = 0.92; 95% CI: 0.46-1.83 for heavy users).

    “No association between snus use and odds of diabetes type 2 in Swedish study (OR = 1.00, 95% CI: 0.47-2.11)and in Norwegian study (OR = 0.91; 95% CI; 0.75-1.10for diabetes type 2 in snus ever users; OR = 0.92; 95% CI: 0.46-1.83for diabetes type 2 in heavy snus users) (Rasouli et al. 2017)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rasouli et al. 2017 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data
    § Study Selection

    Removing duplicate publications between the searched databases reduced the number of publications to 1,241, which were analyzed by title and abstract.

    “Removing duplicate publications between the searched databases allowed to reduce the number of publications to n = 1,241, which were analyzed by the title and abstract.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims. The quote only partly states this claim.

    Findingcitation
    § Norberg et al.

    Exclusive use of snus is not associated with metabolic syndrome at ages 16, 21, 30, and 43; it is positively associated with increased triglycerides at ages 16, 21, and 30, high blood pressure at ages 21, 30, and 43, and impaired fasting glucose at age 21.

    “no association between exclusive use of snus and the metabolic syndrome at age 16, 21, 30 and 43 years-old.Moreover, there was a positive association between exclusive use of snus and an increase in triglycerides level at age 16 (OR = 1.83; 95% CI: 1.11-3.01),21 (OR = 2.05; 95% CI: 1.11-3.79)and 30 (OR = 2.21; 95% CI: 1.20-4.06)year-olds (for crude model).In addition, there was a positive”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Byhamre et al. 2017 source

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    Among male twins, there is no association between using snus and risk for cardiovascular disease (RR = 1.00; 95% CI: 0.69-1.46), lower risk for ischemic heart disease (RR = 0.85; 95% CI: 0.51-1.41), and increased risk for stroke (RR = 1.18; 95% CI: 0.67-2.08) compared to never-users.

    “no association between using snus and risk for cardiovascular disease (risk ratio (RR) = 1.00; 95% CI: 0.69-1.46)and lower risk for ischemic heart disease (IHD) (RR = 0.85; 95% CI: 0.51-1.41)compared to never-users.However, there was an increased risk for stroke (RR = 1.18; 95% CI: 0.67-2.08)among snus users compared to never-users (Hansson et al. 2009).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hansson et al. 2009 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    Among snuff users compared to never-users, there are no excess risks of mortality or hospitalization from ischemic heart disease (IRR = 0.8; 95% CI: 0.5-1.2) or stroke (IRR = 1.1; 95% CI: 0.7-1.8).

    “no excess risks of mortality or hospitalization from IHD (incidence rate ratio (IRR) = 0.8; 95% CI: 0.5-1.2,)or stroke (IRR = 1.1; 95% CI: 0.7-1.8)compared to never-users (Haglund et al. 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Haglund et al. 2007 source

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Offspring of fathers who started using snus in puberty have higher odds of current allergic asthma (OR = 1.42; 95% CI: 1.02-1.97), at least three asthma symptoms with allergy (OR = 1.13; 95% CI: 1.10-1.21), chronic bronchitis (OR = 2.17; 95% CI: 1.04-4.54), and eczema (OR = 1.45; 95% CI: 1.27-1.65), but not in offspring of fathers who started using snus after puberty.

    “higher odds of current allergic asthma (OR = 1.42; 95% CI: 1.02-1.97),at least three asthma symptoms with allergy (OR = 1.13; 95% CI: 1.10-1.21),chronic bronchitis (OR = 2.17; 95% CI: 1.04-4.54),and eczema (OR = 1.45; 95% CI: 1.27-1.65) in offsprings of fathers who started using snus in puberty, but not in offsprings of fathers who started using snus use after puberty (López-Cervantes et al. 2026”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites López-Cervantes et al. 2026 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    ONP use results in lower desire and intention to smoke and anticipation of relief from negative affect compared to baseline, but higher compared to conventional cigarette smoking.

    “Lower desired and intention to smoke and anticipation of relief from negative affect for ONPs use compared to baseline, but higher compared to CC smoke (Liu et al. 2022)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Liu et al. 2022 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Cardiovascular System

    Current snus use is associated with increased risk of heart failure in the ULSAM cohort (HR = 2.08, 95% CI: 1.03-4.22) and in the construction workers cohort (HR = 1.28; 95% CI: 1.00-1.64) compared to never-users.

    “association of current snus use with increased risk of heart failure (hazard ratio (HR) = 2.08, 95% CI: 1.03-4.22for Uppsala Longitudinal Study of Adult Men (ULSAM) cohort; HR = 1.28; 95% CI: 1.00-1.64for construction workers cohort (CWC)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Arefalk et al. 2012 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    Among snus users, oral lesion was found in 89%, mucosal erythema in 32%, and gingival recession in 52%; hyperkeratosis was found in 79%, and odds of hyperkeratosis increased with the number of snus use.

    “oral lesion, mucosal erythema and gingival recession in 89%, 32% and 52% of snus users, respectively.Moreover, users of such products showed hyperkeratosis (79%), and odds of hyperkeratosis increased with the number of snus use (OR = 18.5 for 5-10 snus per day; OR = 2.95 for 11-15 snus per day; OR = 5.21 for 16-20 snus per day; p = 0.0007) (Daneshian et al. 2026).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Daneshian et al. 2026 source

  • May combine two claims.

    Findingcitation
    § Gastrointestinal Health

    Daily snus users compared to never users have reduced odds of gastroesophageal reflux symptoms (OR = 0.77; 95% CI: 0.64-0.93); former snus users and those using < 2 boxes per month have increased odds (OR = 1.20; 95% CI: 1.00-1.46 and OR = 1.41; 95% CI: 1.02-1.96, respectively).

    “reduced odds of gastroesophageal reflux symptoms (GERS) in daily snus users compared to never users (OR = 0.77; 95% CI: 0.64-0.93).However, former snus users and those using < 2 boxes of snus per month showed increased odds (OR = 1.20; 95% CI: 1.00-1.46and OR 1.41, 95% CI: 1.02-1.96,respectively) of GERS (Lie et al. 2017).”
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    • cites Lie et al. 2017 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Risk of Cancer Development

    Among ever snus users compared to never-users, there is an increased risk of pancreatic cancer (RR = 2.0; 95% CI: 1.2-3.3) and reduced risk for oral (RR = 0.8; 95% CI: 0.4-1.7) and lung cancer (RR = 0.8; 95% CI: 0.5-1.3).

    “increased risk of pancreatic cancer (RR = 2.0; 95% CI: 1.2-3.3),but reduced risk for oral (RR = 0.8; 95% CI: 0.4-1.7)and lung cancer (RR = 0.8; 95% CI: 0.5-1.3)among ever snus users compared to never-users (Luo et al. 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Luo et al. 2007 source

  • May combine two claims.

    Findingcitation
    § Hergens et al.

    Snus users compared to never-users have increased odds of high blood pressure at baseline (aOR = 1.23; 95% CI: 1.15-1.33), during follow-up (aOR = 1.39; 95% CI: 1.08-1.79), and of hypertension (aOR = 1.36; 95% CI: 1.07-1.72).

    “increased odds of high blood pressure at baseline (adjusted odds ratio (aOR) = 1.23; 95% CI: 1.15-1.33)and during follow-up (aOR = 1.39; 95% CI: 1.08-1.79),as well as increased odds of hypertension (aOR = 1.36; 95% CI: 1.07-1.72)among snus users compared to never-users (Hergens et al. 2008).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hergens et al. 2008 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    ONP users have lower desire and intention to smoke and anticipation of relief from negative affect.

    “Lower desired and intention to smoke and anticipation of relief from negative affect in ONPs users (Rensch et al. 2021)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rensch et al. 2021 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    After switching to ONPs, there is a reduction in gingival irritation (from 43.5% to 4.3%) and gingivitis (from 13% to 0%), but no gingival recession (39.1% before and after ONP use).

    “Reduce in gingival irritation (from 43.5% to 4.3%), gingivitis (from 13% to 0%), but no gingival recession (39.1% before and after ONP use) after switching to ONPs (Rosa et al. 2025)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Rosa et al. 2025 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    ONP users have oral mucosal changes, including leathery white lesions, round white lesions, dot-like lesions, and white linear lesions.

    “oral mucosal changes in ONP users.Such changes included leathery white lesions, round, white lesions, dot-like lesions and white, linear lesions (Miluna et al. 2022).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Miluna et al. 2022 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Cardiovascular System

    Current snus use is associated with increased risk of non-ischemic heart failure in the ULSAM cohort (HR = 2.55, 95% CI: 1.12-5.82) and in the construction workers cohort (HR = 1.28, 95% CI: 0.97-1.68) compared to never-users.

    “non-ischemic heart failure (HR = 2.55, 95% CI: 1.12-5.82for ULSAM cohort; HR = 1.28, 95% CI: 0.97-1.68 for CWC) compared to never-users (Arefalk et al. 2012).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Arefalk et al. 2012 source

  • May combine two claims.

    Findingcitation
    § Carlsson et al.

    There is a similar prevalence of hypercholesterolemia (25.6% vs. 25.3%) and diabetes (9.8% vs. 9.2%) among snus users and non-users.

    “similar prevalence of hypercholesterolemia (25.6% vs. 25.3%cases) and diabetes (9.8% vs. 9.2% cases) among snus users and non-users (Titova et al. 2021).”
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    • cites Titova et al. 2021 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Early initiation of snus use is positively associated with having three or more asthma symptoms in women (OR = 2.70; 95% CI: 1.46-5.00) and a higher asthma symptom score in women (β = 0.35; 95% CI: 0.07-0.63), but not significantly in men.

    “early initiation of snus use was positively associated with having three or more asthma symptoms (OR = 2.70; 95% CI: 1.46-5.00for women; OR = 1.23; 95% CI: 0.78-1.94for men) and a higher asthma symptom score (β-coefficient (β) = 0.35; 95% CI: 0.07-0.63 for women; β = 0.16; 95% CI: -0.06-0.38 for men).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites López-Cervantes et al. 2024b source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    Among never-smoking middle-aged men, using snus is positively associated with increased risk of hypertension (aHR = 1.64; 95% CI: 1.36-1.98) and heart failure mortality (aHR = 1.75; 95% CI: 1.17-2.62), but not with coronary heart disease or stroke mortality, compared to never-users.

    “using snus among never-smoking middle-aged men was positively associated with an increased risk of hypertension (aHR = 1.64; 95% CI: 1.36-1.98)and heart failure (aHR = 1.75; 95% CI: 1.17-2.62)mortality, but not with coronary heart disease (aHR = 1.10; 95% CI: 0.76-1.59)and stroke (aHR = 1.12; 95% CI: 0.74-1.70)mortality compared to never-users (Loennberg et al. 2026).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Loennberg et al. 2026 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    There is a reduction in craving a cigarette after use of 1.5 mg, 2 mg, 3.5 mg, and 4 mg nicotine ONPs, but not after use of 8 mg nicotine ONP, compared to conventional cigarettes and snus.

    “Reduce in craving a cigarette after use of 1.5 mg, 2 mg, 3.5 mg and 4 mg nicotine ONPs, but not after use of 8 mg nicotine ONP compared to CC and snus (Liu et al. 2022)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Liu et al. 2022 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Oral Health

    There is a strong association between the degree of snus-induced lesions and current snus consumption (p < 0.01); there were 3 incident cases of oral cancer (IRR = 2.3; 95% CI: 0.5-6.7), none of which occurred at the site of the original snus-induced lesion.

    “strong association between the degree of snus-induced lesions (SILs) and current snus consumption (hours and grams of snus consumption per day; p < 0.01).Moreover, there was a total of 3 incident cases of oral cancer (IRR = 2.3; 95% CI: 0.5-6.7),but none of which occurred at the site of the original SIL (2 out of 3 of such participants were daily smokers) (Roosaar et al. 2006).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Roosaar et al. 2006 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    In a pooled analysis, there is no association between current snus use and increased risk of acute myocardial infarction (pHR = 1.04, 95% CI: 0.93-1.17); however, among snus users there is an increase in short-term case fatality rate (OR = 1.28; 95% CI: 0.99-1.68).

    “no association between current snus use and an increased risk of acute myocardial infarction (AMI) (pooled hazard ratio (pHR) = 1.04, 95% CI: 0.93-1.17).However, among snus users there was an increase in short-term case fatality rate (OR = 1.28; 95% CI: 0.99-1.68)(Hansson et al. 2012).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hansson et al. 2012 source

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Women who used snus in puberty compared to never-users have higher odds for asthma-like symptoms (OR = 2.54; 95% CI: 1.37-4.70) and for asthma attacks and medication intake (OR = 1.70; 95% CI: 0.87-3.31); there is no significant effect for snus initiation in puberty by males or late initiation in either sex.

    “women who were using snus in puberty compared to never-users had higher odds for asthma-like symptoms (OR = 2.54; 95% CI: 1.37-4.70)and for asthma attacks and medication intake (OR = 1.70; 95% CI: 0.87-3.31).Moreover, there was no significant effect for snus initiation in puberty by males (OR = 1.15; 95% CI: 0.74-1.79)or late initiation in either of the sexes (López-Cervantes et al. 2023).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites López-Cervantes et al. 2023 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    Short-term exposure to ONP (60 min) is associated with increased plaque acidogenicity; chronic ONP exposure (up to 6 weeks) shows significant differences in minimum pH values at 2, 4, and 6 weeks compared to baseline, but no statistically significant changes in mean plaque index.

    “short-term exposure to ONP (60 min) was associated with increased plaque acidogenicity (p < 0.0001 ONPs vs. positive control; p < 0.05 ONP Smooth vs. negative control; p < 0.01 ONP Peppermint vs. negative control).Moreover, for chronic ONP exposure (up to 6 weeks) there were significant differences in the minimum pH values after 2 weeks (p < 0.01), 4 weeks (p < 0.001), and 6 weeks (p < 0.0001) of”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Alizadehgharib et al. 2026 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Neurodegenerative Disorders

    In a pooled analysis, there is an inverse association between using snus and Parkinson's disease risk (pHR = 0.41; 95% CI: 0.28-0.61), more evident in current, moderate-heavy amount, and long-term snus users.

    “inverse association between using snus and Parkinson's disease (PD) risk (pooled hazard ratio (pHR) = 0.41; 95% CI: 0.28-0.61),which was more evident in current (pHR = 0.38; 95% CI: 0.23-0.63),moderate-heavy amount (pHR = 0.41; 95% CI: 0.19-0.90)and long-term snus users (pHR = 0.44; 95% CI: 0.24-0.83)(Yang et al. 2017).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Yang et al. 2017 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    Among snus users, 79.2% reported oral mucosal lesions and 18.4% reported gingival retraction.

    “79.2% of snus users reported oral mucosal lesions.Moreover, 18.4% of participants reported gingival retraction (Kopperud et al. 2023).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kopperud et al. 2023 source

  • May combine two claims.

    Findingcitation
    § Norberg et al.

    Consumption of high doses of snus at baseline is associated with increased odds of metabolic disorder (OR = 1.6; 95% CI: 1.26-2.15), elevated triglycerides (OR = 1.6; 95% CI: 1.30-1.95), and obesity (OR = 1.7; 95% CI: 1.36-2.18) compared to never using snus.

    “consumption of high-doses of snus at baseline was associated with increased odds of metabolic disorder (OR = 1.6; 95% CI: 1.26-2.15)compared to never using snus.Furthermore, using snus was associated with increased odds of elevated triglycerides (OR = 1.6; 95%CI: 1.30-1.95)and obesity (OR = 1.7; 95% CI: 1.36-2.18)(Norberg et al. 2006).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Norberg et al. 2006 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    There is no difference in reductions in urges to smoke after use of 2 mg, 3.5 mg, and 8 mg nicotine ONPs compared to conventional cigarettes and snus; there is a reduction in urges to smoke after use of 1.5 mg and 4 mg nicotine ONPs compared to conventional cigarette and snus.

    “No difference in reductions in urges to smoke after use of the 2 mg, 3.5 mg, and 8 mg nicotine ONPs compared to CC and snus (Liu et al. 2022) Reduce in urges to smoke after use of the 1.5 mg and 4 mg nicotine ONPs compared to conventional cigarette and snus”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Liu et al. 2022 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § Respiratory System

    Among ONP users, negative pulmonary symptoms include chronic sinus infection or bronchitis (20.8%), frequent colds or flu (11.6%), difficulty breathing (40.5%), frequent coughing or wheezing (27.8%), and shortness of breath (40.5%).

    “negative pulmonary symptoms among ONP users, including chronic sinus infection or bronchitis (20.8% of respondents), frequent colds or flu (11.6% of respondents), difficulty breathing (40.5% of respondents), frequent coughing or wheezing (27.8% of respondents), shortness of breath (40.5% of respondents) (Aldali 2026).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Aldali 2026 source

      Checked before — its earlier verdict is held back until a new check runs.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation
    § Carlsson et al.

    The odds of diabetes type 2 grow with increasing weekly snus consumption: OR = 2.1 (95% CI: 0.9-4.9) for > four boxes per week and OR = 3.3 (95% CI: 1.4-8.1) for > five boxes per week.

    “the odds of diabetes type 2 grew with increasing weekly snus consumption; (OR = 2.1; 95% CI: 0.9-4.9 for > four boxes of snus per week; OR = 3.3; 95% CI: 1.4-8.1 for > five boxes per week) (Östenson et al. 2012).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Östenson et al. 2012 source

  • May combine two claims.

    Findingcitation
    § Norberg et al.

    Extensive snus users have larger waist circumference (b = 1.65; 95% CI: 0.86-2.43) and higher levels of HDL-cholesterol (b = 1.66; 95% CI: 0.79-2.53).

    “larger waist circumference (b = 1.65; 95% CI: 0.86-2.43)and higher levels of HDL-cholesterol (b = 1.66; 95% CI: 0.79-2.53)among extensive snus users (Øverland et al. 2013).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Øverland et al. 2013 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    Switching to ONPs significantly reduces modified gingival index and gingival bleeding index at weeks 12 and 24 compared to continuing smoking conventional cigarettes and baseline, and significantly reduces lobene stain index (60%; p < 0.001).

    “switching to ONPs significantly (p < 0.001) reduced modified gingival index (MGI) and gingival bleeding index (BI) at weeks 12 (MGI = 20%; BI = 30%) and 24 (MGI = 28%; BI = 23%) compared to continuing smoking CC and baseline.In addition, switching to ONPs compared to continuing with CC significantly reduced lobene stain index (LSI) (60%; p < 0.001) (Liu et al. 2025, p. 2).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Liu et al. 2025

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    Among exclusive snus users (never used any tobacco products), there is increased risk of total stroke (HR = 1.52; 95% CI: 1.01-2.30), ischemic stroke (HR = 1.63; 95% CI: 1.05-2.54), and cardiovascular disease mortality (HR = 1.70; 95% CI: 1.01-2.87).

    “increased risk of total stroke (HR = 1.52; 95% CI: 1.01-2.30),ischemic stroke (HR = 1.63; 95% CI: 1.05-2.54)and cardiovascular disease (CVD) mortality (HR = 1.70; 95% CI: 1.01-2.87)among snus users who never used any tobacco products (exclusive snus users).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Titova et al. 2021 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Risk of Cancer Development

    There is no significant association between using snus and increased risk of colorectal or anal cancer; however, there is a positive association between snus use and risk of colon cancer (HR = 1.08; 95% CI: 0.91-1.29).

    “no significant association between using snus and an increased risk of colorectal or anal cancer.However, there was a positive association between snus use and the risk of colon cancer (HR = 1.08; 95% CI: 0.91-1.29)(Nordenvall et al. 2011).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Nordenvall et al. 2011 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    ONP users have a lower frequency of gingival recession compared to snus users, and a higher frequency of mucosal erythema, oedema, etch damage, and mucosal ulcers compared to snus users.

    “Lower frequency of gingival recession in ONPs users compared to snus users (Daneshian et al. 2026) Higher frequency of mucosal erythema, oedema, etch damage and mucosal ulcers in ONPs users compared to snus users”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Daneshian et al. 2026 source

  • May combine two claims.

    Findingcitation
    § Autoimmune Disorders

    Snuff users have lower Disease Activity Score 28 joints values up to 6 months compared to never-smokers and up to 2 years compared to former smokers; there is no effect of snuff use on European League Against Rheumatism response up to 1 year.

    “snuff users had lower values of Disease Activity Score 28 joints (DAS28) up to 6 months of followup compared to never-smokers, as well as lower DAS28 values up to 2 years of follow-up compared to former smokers.Moreover, there was no effect of snuff use on European League Against Rheumatism response for up to 1 year (Andersson et al. 2013).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Andersson et al. 2013 source

  • May combine two claims.

    Findingcitation
    § Gastrointestinal Health

    Among ONP users, gastrointestinal symptoms include bloating (66.7%), nausea (47.9%), heartburn (46.7%), stomach pain (46.5%), constipation (45.3%), and diarrhea (36.6%).

    “gastrointestinal symptoms among ONP users, including bloating (66.7% of respondents), nausea (47.9% of respondents), heartburn (46.7% of respondents), stomach pain (46.5% of respondents), constipation (45.3% of respondents) and diarrhea (36.6% of respondents) (Al-Nafisi et al. 2025).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Al-Nafisi et al. 2025 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    Among never smoking snus users compared to never-users, there are lower adjusted relative risks for nonfatal myocardial infarction (aRR = 0.91; 95% CI: 0.81-1.02) and increased adjusted relative risk for fatal myocardial infarction (aRR = 1.28; 95% CI: 1.06-1.55).

    “lower adjusted relative risks (adjusted risk ratio (aRR) = 0.91; 95% CI: 0.81-1.02)for nonfatal cases and increased adjusted relative risk (aRR = 1.28; 95% CI: 1.06-1.55)for fatal cases of myocardial infarction (MI) among never smoking snus users compared to never-users (Hergens et al. 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hergens et al. 2007 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Cardiovascular System

    During 30 min ONP use, there is an increase in systolic blood pressure up to 3%, diastolic blood pressure up to 7.4%, and heart rate up to 3.2%; 30 min post exposure, there is an increase in systolic blood pressure (3% for 9 mg ONP), diastolic blood pressure (4.5% for 6 mg and 7.4% for 9 mg ONPs), and heart rate (3.2% for 9 mg ONP).

    “increase in SBP (up to 3%), DBP (up to 7.4%) and HRT (up to 3.2%) during 30 min ONPs (6 mg and 9 mg nicotine) use.Moreover, 30 min post exposure there was an increase in SBP (3% for 9 mg ONP), DBP (4.5% for 6 mg and 7.4% for 9 mg ONPs) and HR (3.2% for 9 mg ONP) (Renard et al. 2025).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Renard et al. 2025 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    Over one third of ONP users had changes in taste or smell (36.7%) and almost one out of ten reported yellowing teeth (9.4%).

    “over one third of ONPs users had changes in taste or smell (36.7%) and almost one out of ten reported yellowing teeth (9.4%) (Aldali 2026).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Aldali 2026 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Metabolic Disorders

    Among ever snus users compared to never-users, there are increased odds of diabetes type 2 (OR = 1.34; 95% CI: 0.65-2.7); among current snus users, OR = 1.18; 95% CI: 0.48-2.9.

    “increased odds of diabetes type 2 in ever snus users (OR = 1.34; 95% CI: 0.65-2.7)and in current snus users (OR = 1.18; 95% CI: 0.48-2.9)compared to never-users (Eliasson et al. 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Eliasson et al. 2004 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Oral Health

    Regular snus users compared to never-users have more gum bleeding while toothbrushing (60% vs. 37%; p = 0.004) and presence of ulcerous oral mucosal lesions coinciding with snus placement.

    “more gum bleeding while toothbrushing in regular snus users compared to never-users (60% vs. 37%; p = 0.004), as well as presence of ulcerous oral mucosal lesions coinciding with snus placement (Németh et al. 2024).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Németh et al. 2024 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § 2022) aHR -adjusted hazard ratio; Aix75 -augmentation index normalized to a heart rate of 75 bpm; AMI -acute myocardial infarction; aORadjusted odds ratio; AP -arterial pressure; aRR -adjusted relative risk; BP -blood pressure; CC -conventional cigarette; CHD -coronary heart disease; CI -confidence interval; CPD -cigarettes per day; CVD -cardiovascular disease; CWC -construction workers cohort; DAS28 -Disease Activity Score 28 joints; DBP -diastolic blood pressure; GERS -gastroesophageal reflux symptoms; HDL -high-density lipoprotein; HE -hand eczema; HR -hazard ratio; HRT -heart rate; ID -intellectual disability; IHD -ischemic heart disease; IRR -incidence rate ratio; LADA -latent autoimmune diabetes in adults; MI -myocardial infarction; OR-odds ratio; PD -Parkinson's disease; pHR -pooled hazard ratio; PPR -participation-to-prevalence ratio; pRR -pooled relative risk; PWV -pulse wave velocity; RA -rheumatoid arthritis; RR -relative risk; SAGA -born small for gestational age; SBP -systolic blood pressure; SI -stroke volume index; SIL -snus-induced lesion; SPD -snus per day; T2D -diabetes type 2; ULSAM -Uppsala Longitudinal Study of Adult Men

    In a pooled analysis, there is no association between using snus and risk of any stroke subtypes (HR = 1.04, 95% CI: 0.92-1.17); among snus users who had experienced a stroke, there are increased odds of 28-day case fatality (OR = 1.42; 95% CI: 0.99-2.04) and risk of death during follow-up (HR = 1.32; 95% CI: 1.08-1.61).

    “no associations between using snus and the risk of any stroke subtypes (HR = 1.04, 95% CI: 0.92-1.17).Among snus who had experienced a stroke, there were increased odds of 28-day case fatality (odds ratio (OR) = 1.42; 95% CI: 0.99-2.04)and the risk of death during the follow-up period (HR = 1.32; 95% CI: 1.08-1.61)(Hansson et al. 2014).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hansson et al. 2014 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingcitation
    § Mental Health

    There is a positive association between using snus and non-affective psychosis (aHR = 1.22, 95% CI: 1.00-1.48), but not schizophrenia (aHR = 1.03, 95% CI: 0.70-1.54).

    “positive association between using snus and non-affective psychosis (aHR = 1.22,95% CI: 1.00-1.48),but not schizophrenia (aHR = 1.03, 95% CI: 0.70-1.54)(Munafò et al. 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Munafò et al. 2007 source

  • May combine two claims.

    Findingcitation
    § Oral Health

    Use of ONPs is associated with increased prevalence of quit electronic nicotine delivery system (aPR = 6.28; 95% CI: 2.77-14.25) and non-ENDS (aPR = 2.00; 95% CI: 1.19-3.37).

    “Use of ONPs was associated with increased prevalence of quit electronic nicotine delivery system (ENDS) (aPR = 6.28; 95% CI: 2.77-14.25)and non-ENDS (aPR = 2.00; 95% CI: 1.19-3.37)(Lee et al. 2026)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Lee et al. 2026 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation
    § Additional information

    15.3% of ONPs users reported taste alteration.

    “15.3% of ONPs users reported taste alteration (Alkharaan et al. 2025)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Alkharaan et al. 2025 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingnone given
    § Discussion

    There is evidence for increased risk of asthma, and a weak association between using snus and schizophrenia and non-affective disorders, but not for anxiety and depression.

    “In addition, there is evidence for increased risk of asthma, and a weak association between using snus and schizophrenia and non-affective disorders, but not for anxiety and depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation
    § Oral Health

    There are higher odds of quitting smoking after switching to fruit-flavored ONPs (OR = 1.29; 95% CI: 1.04-1.59; p = 0.017), but not after switching to mint-flavored ONPs (OR = 1.04; 95% CI: 0.82-1.28; p = 0.75).

    “A higher odds of quitting smoking (OR = 1.29; 95% CI: 1.04-1.59;p = 0.017) after switching to fruit-flavored ONPs, but not after switching to mint-flavored ONPs (OR = 1.04; 95% CI: 0.82-1.28;p = 0.75) (McDowell et al. 2024)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites McDowell et al. 2024 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingnone given
    § Conclusions

    Current literature confirms negative health consequences associated with regular using snus, especially for cardiovascular system, metabolic disorders, oral mucosal changes, asthma, as well as increased risk of cancer and pregnancy complications.

    “Current literature confirms negative health consequences associated with regular using snus, especially for cardiovascular system, metabolic disorders, oral mucosal changes, asthma, as well as increased risk of cancer and pregnancy complications.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation
    § Additional information

    18.6% of ONPs users reported frequent coughing.

    “18.6% of ONPs users reported frequent coughing”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Alkharaan et al. 2025 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Findingnone given
    § Discussion

    Switching to ONPs reduced the number of smoked cigarettes per day, urges to smoke, as well as increased odds of quitting smoking.

    “Finally, switching to ONPs reduced the number of smoked cigarettes per day, urges to smoke, as well as increased odds of quitting smoking.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § Discussion

    This systematic review showed that using ONPs increased blood pressure, heart rate, respiratory and gastrointestinal symptoms, and oral mucosal changes.

    “This systematic review showed that using ONPs increased blood pressure, heart rate, respiratory and gastrointestinal symptoms, and oral mucosal changes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Introduction

    Reduction in cell apoptosis and an increase in cell proliferation were observed after snus and TF-ONPs exposure.

    “reduction in cells apoptosis (reduced expression of caspase-3, caspase-8, caspase-9, Fas, Fas L, Bax, p21) and an increase in cells proliferation (increased expression of PCNA, cyclin D1, cyclin dependent kinase 4) was observed (Ranjani et al. 2020).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Ranjani et al. 2020 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review

    Snus and TF-ONPs are especially popular among young people and never-smokers who would like to try modern tobacco products.

    “They are especially popular among young people and neversmokers, who would like to try some modern tobacco products (Travis et al. 2024).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Travis et al. 2024 source

      Checked before — its earlier verdict is held back until a new check runs.

  • May combine two claims.

    Premisecitation
    § Introduction

    Toxicological assessment indicates activation of DNA damage, oxidative stress, and inflammatory response after snus and TF-ONPs exposure.

    “toxicological assessment indicated activation of DNA damage (i.e.8-OH-dG, DNA adducts, double-strand breaks (DSBs), oxidative stress (increased level of reactive oxygen species (ROS), increased activity of LDH) and inflammatory response”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Smith et al. 1997 source
    • cites Costea et al. 2010 source
    • cites Ranjani et al. 2020 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review

    The popularity of snus and tobacco-free oral nicotine pouches in the population has lately been increasing.

    “The popularity of snus and tobacco-free oral nicotine pouches in the population has lately been increasing.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Travis et al. 2024 source

      Checked before — its earlier verdict is held back until a new check runs.

  • Classified as probably not a substantial claim.

    Study design and conductcitation
    § Quality Assessment of Included Studies

    NIH Study Quality Assessment Tools was used to assess the quality of studies included in this systematic review.

    “NIH Study Quality Assessment Tools (National Institutes of Health 2024) was used to assess the quality of studies included in this systematic review.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites National Institutes of Health 2024

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Study Selection

    Consensus for discrepancies between the authors' opinions on study relevance and inclusion was achieved by discussion.

    “Consensus in the case of any discrepancies between the authors' opinions on the relevance of some individual studies and their inclusion into further investigation was achieved by discussion.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given
    § Eligibility Criteria

    Pre-determined inclusion and exclusion criteria were used to select relevant publications.

    “Pre-determined inclusion and exclusion criteria were used to select relevant publications.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation
    § Risk of Bias Assessment of Included Studies

    Risk of bias for randomized controlled trials, cohort and case-control studies was assessed by Clarity to Assessed Risk of Bias Tools.

    “The risk of bias for randomized controlled trials, cohort and case-control studies was assessed by Clarity to Assessed Risk of Bias Tools (Clarity Research 2025).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Clarity Research 2025

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation
    § Risk of Bias Assessment of Included Studies

    Risk of bias for observational studies was assessed by the JBI Critical Appraisal Checklist for Quasi-Experimental Studies.

    “Finally, the risk of bias for observational studies has been assessed by the JBI Critical Appraisal Checklist for Quasi-Experimental Studies (Martin 2017).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Martin 2017

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Study Selection

    Both authors conducted an independent selection of publications to select potentially relevant human studies for further analysis.

    “Both authors (P.N.K-S. and R. P.) conducted an independent selection of publications to select potentially relevant human studies for further analysis in this systematic review.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data
    § Discussion

    A vast majority of the studies included in this systematic review had observational, case-control or cross-sectional design, which prevents establishing causality between using snus and/or ONP and the observed outcomes.

    “Thirdly, a vast majority of the studies included to this systematic review had observational, case-control or cross-sectional design, which prevents establishing causality between using snus and/or ONP and the observed outcomes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning
    § Risk of Bias

    Only one of the studies (a cross-sectional study) was ranked as high risk of bias, because of self-reported data (exposure and outcomes), lack of justification of sample size as well as adjustment and assessment of confounders.

    “Only one of the studies (a crosssectional study) was ranked as high risk of bias, because of self-reported data (exposure and outcomes), lack of justification of sample size as well as adjustment and assessment of confounders.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given
    § Discussion

    The quality of the presented studies was not always satisfactory, which increases the possibility of bias, introduces uncertainty of the findings and weakens trust in the results.

    “Finally, the quality of the presented studies was not always satisfactory, which increases the possibility of bias, introduces uncertainty of the findings and weakens trust in the results.”
    Quote in the paperSubstantial claim
105 of 105

  • The paper relies on this without support.

    The reported associations are not substantially affected by reverse causation or other biases in the included studies.

    “Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches”
1 of 1

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Small-for-gestational-age conclusion contradicts reported result

    Major

    The discussion says maternal snus use increased the risk of a newborn being small for gestational age, whereas Table 5 explicitly reports no association.

  • Maternal snus-preschool asthma claims conflict

    Major

    The abstract attributes increased preschool asthma risk to maternal snus use, but the reported study found no association for maternal use during pregnancy. The separately reported association for parental pre-conception use does not resolve that discrepancy.

  • Reduced rheumatoid arthritis risk conflicts with no association

    Minor

    The discussion describes a reduced risk of rheumatoid arthritis, but the reported case-control result explicitly says there was no association. Lower disease-activity scores among people with rheumatoid arthritis are a different outcome from risk of developing it.

  • Very and moderately preterm ranges overlap

    Minor

    The stated "very" preterm category of more than 32 weeks overlaps the moderately preterm category of 32-36 weeks, so these categories do not distinguish the two reported outcomes.

  • Moderate and low risk-of-bias ranges overlap

    Minor

    For the nine-point observational-study tool, a score of 6 is classified as both moderate and low risk of bias.

  • Nordenvall sample is smaller than its stated male count

    Minor

    The row lists 366,381 male participants but gives a total sample size of 336,381.

  • Hyperkeratosis odds do not increase across the stated use categories

    Minor

    The text says the odds increase with the number of snus portions used, but the quoted odds ratio drops from 18.5 for 5-10 per day to 2.95 for 11-15 per day.

  • Opposite directions reported for the 11.2 mg heart-rate change

    Minor

    The prose reports a 0.2% increase in heart rate 30 minutes after exposure, while Table 6 reports a 0.2% decline for the 11.2 mg product at the same time point.

  • Schizophrenia is described as both associated and unassociated

    Minor

    The abstract reports a weak association with schizophrenia, while the results explicitly report no association with schizophrenia.

9 of 9

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Natvig Norderhaug I, Dybing E, Gilljam H et al (2005) Health Effects and Dependency Associated with Snuff Consumption. Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH), Oslo, Norway
  2. Walsh PM, Epstein JB (2000) The oral effects of smokeless tobacco. J Can Dent Assoc 66:22–25

Cited by

Still being checked.

Related

Authors
Kopa-Stojak, P. N., & Pawliczak, R.
Affiliations
Medical University of Lodz (PL)
ORCID
Kopa-Stojak, Paulina Natalia
Venue
Exposure and Health
Publisher
Springer Science and Business Media LLC
Published
2026-10
Volume
18
Issue
5
ISSN
  • 2451-9685 (ISSN-L)
  • 2451-9766
DOI
10.1007/s12403-026-00812-w
OpenAlex
W7220747014
Semantic Scholar
330caedb3a94bb6e915dbffca2d0fbe3d714c5dc
Cited by
0
References
211
FWCI
0.00
Type
journal article
Language
en
Open access
Licence
Locations
Exposure and Health (publishedVersion, cc-by)
Funders
Uniwersytet Medyczny w Lodzi (503/0-149-03/503-01-001)
Topics
  • Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
  • Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
  • Health Sciences › Dentistry › Periodontics › Oral Health Pathology and Treatment
Keywords
snus, health effects, cardiovascular risk, hypertension, stroke, type 2 diabetes, cancer risk, schizophrenia, pregnancy complications, smoking cessation, nicotine dependence, oral mucosal changes

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-11-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-11-06.

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