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Swedish snuff (snus) and risk of cardiovascular disease and mortality: prospective cohort study of middle-aged and older individuals

Titova, Olga E., Baron, John A., Michaëlsson, Karl, Larsson, Susanna C.·2021·BMC Medicine
DOI 10.1186/s12916-021-01979-6PMC PMC8103653
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Abstract

Background: Cigarette smoking is a well-known risk factor for cardiovascular disease (CVD), but whether smokeless tobacco such as snuff is associated with the risk of CVD is still unclear. We investigated the association of the use of Swedish oral moist snuff (snus) with a broad range of CVDs and CVD mortality. Methods: We used data from a population-based cohort of 41,162 Swedish adults with a mean baseline age of 70 (56–94) years who completed questionnaires regarding snus use and other lifestyle habits and health characteristics. Participants were followed up for incident cardiovascular outcomes and death over 8 years through linkage to the Swedish National Patient and Death Registers. Hazard ratios (HR) were estimated by Cox proportional hazards regression. We conducted analyses among all subjects as well as among never smokers to reduce residual confounding from smoking. Results: After adjustment for smoking and other confounders, snus use was not associated with myocardial infarction, heart failure, atrial fibrillation, aortic valve stenosis, abdominal aortic aneurysm, stroke, or CVD mortality. However, in never smokers, snus use was associated with a statistically significant increased risk of total and ischemic stroke (HRs [95% confidence intervals] = 1.52 [1.01–2.30] and 1.63 [1.05–2.54], respectively) and non-significantly positively associated with some other CVDs. Conclusions: In this middle-aged and elderly Swedish population, current Swedish snus use was not associated with the risk of major heart and valvular diseases, abdominal aortic aneurysm, or CVD mortality in the entire study population, but was linked to an increased risk of stroke in never smokers.

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  • 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).”

    From Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review (2026) · cites this paper as Titova et al. 2021

    The Abstract Results report the quoted hazard ratios for total and ischemic stroke among snus users who had never smoked. In Results, Table 3 reports the quoted CVD-mortality HR of 1.70 only for the age- and sex-adjusted model; the multivariable estimate is 1.58 (95% CI 0.94–2.67), which is not statistically significant. Table 3 defines the subgroup as people who reported never smoking cigarettes regularly, not people who had never used any tobacco products. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • The prevalence of diabetes is similar among snus users and non-users (9.8% vs. 9.2%).

    “Similar prevalence of diabetes (9.8% vs. 9.2% cases) among snus users and non-users (Titova et al. 2021)”

    From Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review (2026) · cites this paper as Titova et al. 2021

    The Methods section says participants reported a history of diabetes, but gives no prevalence by snus use. The retrieved portion of Table 1 in Results ends before any diabetes row; searches for 9.8% and 9.2% did not yield the claimed figures, so the comparison cannot be verified from the available passages. (LLM, conf=0.70)

    Experimental — accuracy not yet measured

  • 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).”

    From Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review (2026) · cites this paper as Titova et al. 2021

    The Methods say participants reported histories of diabetes and hypercholesterolemia, and the Results present baseline characteristics by snus use in Table 1. However, the available Table 1 passage does not show either condition's prevalence; searches for the stated percentages and condition-specific rows did not retrieve them. Our copy therefore does not verify the four figures or their similarity. (LLM, conf=0.72)

    Experimental — accuracy not yet measured

  • There is a similar frequency of hypertension among snus users and non-users (38.6% vs. 41.7%).

    “There was a similar frequency of hypertension (38.6% vs. 41.7%)among snus users and non-users (Titova et al. 2021).”

    From Comparison of the Health Effects Associated with the Use of Snus and Tobacco-Free Oral Nicotine Pouches: A Systematic Review (2026) · cites this paper as Titova et al. 2021

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Cited by

Sorted by citations

Authors
Titova, O. E., Baron, J. A., Michaëlsson, K., & Larsson, S. C.
Venue
BMC Medicine
Publisher
Springer Science and Business Media LLC
Published
2021-05-07
Volume
19
Issue
1
ISSN
1741-7015
DOI
10.1186/s12916-021-01979-6
PMC
PMC8103653
Cited by
35
References
2
Language
en
Licence
Funders
  • the Geriatric Foundation, research for healthy aging
  • Börjeson, Emil and Ragna Foundation
  • Swedish Research Council for Health, Working Life and Welfare (2018-00123)
  • Vetenskapsrådet (2016-01042 and 2019-00977)
  • Hjärt-Lungfonden (20190247)
  • Uppsala University

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