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Smokeless Tobacco (Snus) and Risk of Heart Failure of Ischemic and Non-Ischemic Origin: a Pooled Analysis of Eight Prospective Cohort Studies
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

Snus, a Swedish type of smokeless tobacco, has potent acute hemodynamic effects, which could provoke stress on the cardiovascular system, including the myocardium. Snus has, however, not been linked to risk of ischemic heart disease. Therefore, we hypothesized that snus use increases the risk for heart failure of non-ischemic origin.

Methods

We conducted a pooled analysis of eight Swedish prospective cohort studies involving individual participant data from 350,711 men. Shared frailty models with random effects at the cohort level, were used to estimate hazard ratios (HRs) with 95 % confidence intervals (CIs) of heart failure in relation to snus use. We investigated dose-response associations, and association with ischemic and non-ischemic heart failure in separate. For positive control purposes, we also investigated associations between smoking and risk of heart failure.

Results

During a median follow-up time of 16 years, 5,404 men were hospitalized for heart failure. In models adjusting for age, smoking, previous myocardial infarction and educational level, current snus use was associated with a higher risk of heart failure (HR 1.27, 95 % CI 1.07-1.50), relative to non-current snus use. A dose-response pattern was observed, with higher risk with more snus cans used per week. We observed an association of snus use with non-ischemic heart failure, HR 1.34 (95 % CI 1.11-1.63), but not with ischemic heart failure, HR 1.01 (95 % CI 0.72-1.42). Smoking was more strongly associated with heart failure, particularly of ischemic origin, than snus use.

Conclusions

Snus use was associated with a modestly increased risk for heart failure of non-ischemic origin in a dose-response manner. This finding has public health implications for the risk assessment of snus use, and potentially other modes of smokeless use of nicotine.

National Category
Cardiac and Cardiovascular Systems Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Cardiology; Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-345868OAI: oai:DiVA.org:uu-345868DiVA, id: diva2:1191337
Available from: 2018-03-18 Created: 2018-03-18 Last updated: 2018-03-22
In thesis
1. Smokeless Tobacco (Snus) and Cardiovascular Disease: Associations with Heart Failure and Prognosis after Myocardial Infarction
Open this publication in new window or tab >>Smokeless Tobacco (Snus) and Cardiovascular Disease: Associations with Heart Failure and Prognosis after Myocardial Infarction
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Previous investigations of snus use (oral moist snuff, a Swedish form of smokeless tobacco) and cardiovascular disease have generally focused on atherosclerotic events such as myocardial infarction and stroke, likely because smoking is such a well-established risk factor for atherosclerotic disease. Smokeless administration of tobacco circumvents most of the atherogenic effects of the combusted products from smoked tobacco, but it is possible that the potent autonomic and hemodynamic effects of snus and nicotine per se are detrimental for cardiovascular tissues.

The aim of this thesis was to investigate if snus is associated with development of heart failure and the prognosis after myocardial infarction. We used data from Swedish cohort studies and the national quality register for myocardial infarctions (SWEDEHEART), with linkages to national registers.

Snus use was associated with a higher risk of heart failure in a dose-response manner. This association was specific to non-ischemic heart failure, implying a direct myocardial effect, rather than an atherogenic effect (papers I and II).

Acute, short-term or long-term outcomes following a myocardial infarction were not consistently worse among snus users relative to snus non-users, although snus use was associated with an increased risk of death after myocardial infarction among never-smokers (paper III).

Discontinuation of snus use after a myocardial infarction was associated with an almost halved mortality risk, similar to the benefit associated with smoking cessation (paper IV).

Although smoking was consistently stronger related to all adverse outcomes, and with reservations due to the observational design, the findings from this thesis indicate that snus should not be regarded as harmless. Snus use was associated with a higher risk of heart failure and post-myocardial infarction mortality, which may have public health implications for the risk assessment of snus, and potentially other modes of smokeless nicotine.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 67
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1445
Keywords
Snus, smokeless tobacco, nicotine, cardiovascular disease, heart failure, myocardial infarction, mortality, prognosis, epidemiology
National Category
Clinical Medicine Cardiac and Cardiovascular Systems Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:uu:diva-345869 (URN)978-91-513-0283-6 (ISBN)
Public defence
2018-05-09, Enghoffsalen, Akademiska Sjukhuset, ingång 50 BV, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-18 Created: 2018-03-18 Last updated: 2018-04-18

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Arefalk, GabrielSundström, Johan

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