title: Smokeless tobacco and coronary heart disease: a 12-year follow-up study.
abstract: BACKGROUND
  Cigarette smoking has declined whereas the use of smokeless tobacco is increasing. There is an ongoing debate as to whether smokeless tobacco is a recommendable strategy to help smokers to quit. However, very few studies have examined the association between smokeless tobacco, namely snuff, and coronary heart disease, which implies that it has not been possible to provide scientific results for public health policies and clinical guidelines concerning the use of smokeless tobacco.
  
  
  METHODS
  A follow-up study.
  
  
  METHODS
  A random sample of 3120 healthy men aged 30-74 years was interviewed in 1988 and 1989 and followed up to the year 2000 with regard to coronary heart disease. Cox regression was used to estimate the relative risk of coronary heart disease in six categories of smoking and snuffing habits, after adjustment for established risk factors for coronary heart disease.
  
  
  RESULTS
  Smokers, former smokers, and those who combined smoking and snuffing had significantly higher hazard ratios than never-smokers. The very highest hazard ratio was found among individuals combining smoking and snuffing. Daily snuffers had a hazard ratio of 1.62 (95% confidence interval 0.70-3.03) after adjustment for age.
  
  
  CONCLUSIONS
  Even though the association between daily snuffing and coronary heart disease was non-significant, the hazard ratio was markedly increased. Therefore, smokers should not use smokeless tobacco in order to quit smoking, especially as safer alternatives are available. Further studies in different settings are required to provide scientific results for public health policies and clinical guidelines.
authors.affiliation: Center for Family Medicine, Karolinska Institute, Huddinge, Sweden bStatistics Sweden, Stockholm, Sweden.
authors.forename: Sven-Erik
authors.initials: SE
authors.lastname: Johansson
authors.forename: Kristina
authors.initials: K
authors.lastname: Sundquist
authors.forename: Jan
authors.initials: J
authors.lastname: Qvist
authors.forename: Jan
authors.initials: J
authors.lastname: Sundquist
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D003327:Coronary Disease / Q000453:epidemiology / Q000209:etiology* / Q000503:physiopathology; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology / Q000503:physiopathology; D016017:Odds Ratio; D005082:Physical Exertion; D016016:Proportional Hazards Models; D012307:Risk Factors; D013548:Sweden / Q000453:epidemiology; D014030:Tobacco, Smokeless / Q000009:adverse effects*