Smokeless Tobacco: Is It Really a Safer Alternative?
"A deep dive into the latest research reveals surprising differences in heart health risks between U.S. and Swedish smokeless tobacco users."
For years, smokeless tobacco has been touted by some as a "safer" alternative to cigarettes. But is that really the case? The health effects of smokeless tobacco are of considerable research and public health interest. Globally, more than 300 million people use these products, many of them in low-income countries. In the USA, it has been estimated that smokeless tobacco use was responsible for approximately 1600 new cases of oral cancer, 500 new cases of pancreatic cancer and 200 new cases of oesophageal cancer in 2008.
A new systematic review and meta-analysis, published in Open Heart, is shedding light on the circulatory disease risks associated with smokeless tobacco use. This study offers an updated look at the potential dangers, particularly for users in Europe and North America. The aim of this study therefore is to produce an updated systematic review and meta-analysis of smokeless tobacco use and circulatory disease risks, specifically focusing on studies conducted among European and North American smokeless tobacco users. These regions were selected because products from these areas, such as chewing tobacco, moist snuff and snus, are commonly sold in the US market and thus regulated by the US Food and Drug Administration.
This article dives into the findings of this meta-analysis, exploring the differences in risk profiles between different regions and types of smokeless tobacco. We'll break down the key takeaways and what they mean for your heart health. Several reviews of smokeless tobacco use and circulatory disease risks have thus been published, but these reviews have varied in terms of the geographical areas and smokeless tobacco products they covered, the studies they included and the findings they reported.
Evidence on Cardiovascular Risk
Research on smokeless tobacco and cardiovascular disease includes different approaches. One study compared cardiovascular-disease-related harm biomarkers in 4,347 adults in the Population Assessment of Tobacco and Health Study from 2013–2014. Another harmonized tobacco-use data from 15 National Institutes of Health National Heart, Lung, and Blood Institute prospective cohorts through the Cross Cohort Collaboration Tobacco Working Group. A 2024 American Heart Association statement says smokeless oral nicotine products are addictive and may adversely affect some, but not all, cardiovascular-risk biomarkers; some product types have also been associated with increased mortality in people with ischemic heart or cerebrovascular disease.
Debate Over Harm Reduction and New Products
A 2004 article described an ongoing debate about substituting smokeless tobacco for cigarettes as a harm-reduction strategy, noting the general belief at the time that smokeless tobacco posed lower health risks than cigarette smoking. A 2024 American Heart Association review says the market for smokeless oral nicotine products has transformed since its previous smokeless tobacco policy statement. It also notes that oral-cancer risk may depend on a product’s chemical composition. A 2024 CORESTA presentation raises questions about the intended market for emerging tobacco-free nicotine products and whether they could serve as reduced-risk products or cessation aids.
The Great Divide: US vs. Swedish Smokeless Tobacco
The meta-analysis, encompassing 17 cohort studies, 5 case-control studies, one cross-sectional analysis, and two pooled data analyses, revealed a striking contrast between US and Swedish smokeless tobacco users. Researchers found that US smokeless tobacco users faced a significantly increased risk of heart disease and stroke. Meta-analysis results did not show increased risk of heart disease or stroke among smokeless tobacco users in Sweden compared with non-users, but did show increased heart disease and stroke risk for US smokeless tobacco users. These US results were consistent for current smokeless tobacco users compared with never tobacco users and for former smokers who had switched to smokeless tobacco use compared with former smokers who had quit tobacco use entirely.
- Heart Disease: US users showed a 17% increased risk (Relative Risk (RR) 1.17, 95% CI 1.09 to 1.27).
- Stroke: US users had a 28% increased risk (RR 1.28, 95% CI 1.01 to 1.62).
- Swedish Snus: No increased risk of heart disease or stroke was observed among Swedish snus users.
Recent Reviews on Health Outcomes and Use
A systematic review of smokeless tobacco products reported that four meta-analyses—three global analyses covering 14, 20, and 19 studies and one analysis of 24 European Union studies—found no association between snus use and ischemic heart disease in the excerpted results. A separate review reports that smokeless nicotine use has been associated with higher prevalence of oral cancer, stroke, and heart disease, while findings for overall mortality are mixed. In Saudi Arabia, the 2022 Global Youth Tobacco Survey found that 3.6% of adolescents aged 13 to 15 used culturally significant products such as Shammah and Dokha, particularly in the southern and western regions.
Risk Findings Differ by Region
A systematic review and meta-analysis found no increased risk of heart disease or stroke among smokeless tobacco users in Sweden compared with non-users. In contrast, it found increased heart disease and stroke risk among US smokeless tobacco users. The results therefore differ by country in the studies reviewed, rather than supporting a single uniform risk finding across these populations.
What This Means for You
If you're a smokeless tobacco user in the US, this study serves as a stark reminder of the potential dangers to your heart health. The increased risk of heart disease and stroke is significant, and highlights the need for informed decisions about tobacco use.
While Swedish snus may present a different risk profile, it's crucial to remember that no tobacco product is entirely risk-free. several studies comparing constituent levels, use patterns and other characteristics of smokeless tobacco use across product types could help further strengthen our knowledge of the health risks of smokeless tobacco products.
Ultimately, the best course of action for your health is to quit all tobacco use. Talk to your doctor about cessation strategies and resources available to help you break free from tobacco's grip. Practitioner's should advise their patients who use smokeless tobacco products of the known health risks and provide advice on cessation.