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Snus use and mortality: associations, potential mechanisms, and socioeconomic aspects
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.ORCID-id: 0000-0002-6731-1001
2022 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)Alternativ titel
Fint som snus? : snusning, mortalitet och vad som finns däremellan (Svenska)
Abstract [en]

Snus is a smokeless tobacco product made of a moist powder of ground tobacco. It is used mainly in the Nordic countries, although increasingly popular internationally. The Swedish snus tradition dates back to the seventeenth century, and it is now used daily by about 23% of the male and 6% of the female population. Snus contains high levels of nicotine as well as carcinogenic substances and microorganisms that could potentially cause adverse health effects. The physiological effects of snus use include acutely raised blood pressure and heart rate, and increased cardiac oxygen demand, while the psychological response results in alertness and anxiety reduction. The high nicotine content causes rapid onset of addiction. 

Previous research on snus use and health is largely inconclusive, but indicates increased risks of all-cause, cardiovascular and cancer mortality. This thesis aimed to further investigate the health effects of snus use, with a focus on mortality, potential underlying mechanisms, and the impact of socioeconomic factors. 

Four original papers form the base of this thesis. The first study was performed on a pooled dataset of eight Swedish cohorts (The Swedish Collaboration on Health Effects of Snus use), including over 169 000 men. We found an increased risk of all-cause (HR 1.28, 95% CI 1.20; 1.35), cardiovascular, and other cause mortality, and indications of raised cancer mortality. The second study was set within an interventional program in northern Sweden (Västerbotten Intervention Programme) and included 46 000 men and women. It showed increased mortality overall (estimates similar to first study), from cardiovascular diseases, and external causes (e.g., accidents and suicide) that remained after controlling for socioeconomic status. We found these associations in groups of varying socioeconomic background (e.g., both basic education and high-income groups), suggesting that increased mortality risks among snus users are not restricted to certain socioeconomic groups. 

Studies three and four investigated potential underlying mechanisms that might contribute to increased mortality among snus users, including established cardiometabolic risk factors in study three (the metabolic syndrome and its components: obesity, hypertension, type 2-diabetes and abnormal blood lipids) and more novel risk factors in study four (low-grade inflammation, low vitamin D-concentrations, and altered iii testosterone levels). The analytical samples were drawn from a long- term follow-up study of around 900 16-year-olds in a municipality in northern Sweden (Northern Sweden Cohort, study three) and more than 6 000 participants in another population-based cohort (the Northern Sweden MONICA study, study four). We found no associations between snus use and established cardiometabolic risk factors, but there was evidence of lower concentrations of inflammatory and vitamin D-status biomarkers in both men and women, and higher testosterone concentrations in men who were currently using snus. 

We conclude that snus use is associated with increased all-cause and cardiovascular mortality, and to death by other causes, that may be restricted to external causes. Cancer mortality may also be increased among snus users. The associations cannot be fully explained by differences in socioeconomic status among snus users and non-users. Established cardiometabolic risk factors do not seem to be the main mechanisms behind these associations. Lower inflammatory biomarker levels among snus users may serve as a protective factor, while lower vitamin D-concentrations and increased testosterone levels may be part of an underlying mechanism linking snus use to increased mortality. 

Future research should focus on the health consequences of snus use among women, on other possible links between snus use and death, and on mortality in different cancers among users of snus. The health consequences of dual use of snus and cigarettes should also be assessed. 

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University , 2022. , s. 78
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2205
Nyckelord [en]
snus, Swedish snuff, smokeless tobacco, mortality, cardiovascular, cancer, risk factor, metabolic syndrome, C-reactive protein, vitamin D, testosterone
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Forskningsämne
allmänmedicin; befolkningsstudier; epidemiologi; invärtesmedicin; medicin
Identifikatorer
URN: urn:nbn:se:umu:diva-200748ISBN: 978-91-7855-916-9 (tryckt)ISBN: 978-91-7855-917-6 (digital)OAI: oai:DiVA.org:umu-200748DiVA, id: diva2:1708504
Disputation
2022-11-25, Triple Helix, Universitetsledningshuset, Umeå, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2022-11-07 Skapad: 2022-11-04 Senast uppdaterad: 2022-11-07Bibliografiskt granskad
Delarbeten
1. Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies
Öppna denna publikation i ny flik eller fönster >>Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies
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2020 (Engelska)Ingår i: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 49, nr 6, s. 2041-2050Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

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

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

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

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

Ort, förlag, år, upplaga, sidor
Oxford University Press, 2020
Nyckelord
All-cause mortality, Swedish snus, cancer mortality, cardiovascular mortality, moist oral snuff, smokeless tobacco
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi Kardiologi
Identifikatorer
urn:nbn:se:umu:diva-178256 (URN)10.1093/ije/dyaa197 (DOI)000615922900033 ()33347584 (PubMedID)2-s2.0-85100358349 (Scopus ID)
Forskningsfinansiär
Svenska läkaresällskapet, 496881
Tillgänglig från: 2021-01-07 Skapad: 2021-01-07 Senast uppdaterad: 2022-11-04Bibliografiskt granskad
2. Snus use, mortality, and socioeconomic factors
Öppna denna publikation i ny flik eller fönster >>Snus use, mortality, and socioeconomic factors
(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-200746 (URN)
Tillgänglig från: 2022-11-04 Skapad: 2022-11-04 Senast uppdaterad: 2022-11-04
3. Snus use during the life-course and risk of the metabolic syndrome and its components
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2017 (Engelska)Ingår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, nr 8, s. 733-740Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective: We aimed to investigate the association between life-course exposure to snus and prevalence of the metabolic syndrome and its components in adulthood.

Design and method: Tobacco habits at baseline (age 16) and three follow-ups (ages 21, 30 and 43) were assessed among 880 participants in a population-based cohort in Northern Sweden. Presence of the metabolic syndrome at age 43 was ascertained using the International Diabetes Federation criteria. Odds ratios and CIs for risk of the metabolic syndrome and its components by snus use at 16, 21, 30 and 43 years were calculated using logistic regression. Cumulative snus use was defined as number of life periods (1-4) with current snus use.

Results: At age 43, 164 participants (18.6%) were current snus users. We found no association between exclusive snus use at the ages of 16, 21, 30 and 43 years and the metabolic syndrome at age 43 years. Snus use (among non-smokers) was associated with raised triglycerides and high blood pressure in crude analysis, but not in multivariable models. There was no association between cumulative snus use and risk of the metabolic syndrome. Cumulative snus use was associated with central obesity, raised triglycerides and impaired fasting glucose/diabetes mellitus type 2 in crude analyses, but not after adjustments.

Conclusion: The health consequences of snus exposure from adolescence to mid-adulthood do not seem to include increased risk of the metabolic syndrome or its components. The cardio-metabolic risk of dual exposure to snus and cigarettes may warrant further attention.

Ort, förlag, år, upplaga, sidor
Sage Publications, 2017
Nyckelord
Swedish moist snuff, hypertension, life-course, metabolic syndrome, metsy, obesity, smokeless tobacco, snus, triglycerides
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-143321 (URN)10.1177/1403494817706631 (DOI)000418185200001 ()28673132 (PubMedID)2-s2.0-85032261656 (Scopus ID)
Tillgänglig från: 2017-12-20 Skapad: 2017-12-20 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
4. Associations between snus use and concentrations of CRP, 25(OH)D and testosterone – a population-based study
Öppna denna publikation i ny flik eller fönster >>Associations between snus use and concentrations of CRP, 25(OH)D and testosterone – a population-based study
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(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-200747 (URN)
Tillgänglig från: 2022-11-04 Skapad: 2022-11-04 Senast uppdaterad: 2022-11-04

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