title: Circulatory disease and smokeless tobacco in Western populations: a review of the evidence.
abstract: BACKGROUND
  Use of oral snuff or 'snus' has risen in Sweden. Sales of snuff in the US have also risen, overtaking sales of chewing tobacco. There is some evidence that nicotine contributes to circulatory disease (CID) from smoking. We therefore reviewed the evidence relating smokeless tobacco (ST) to CID and related risk factors.
  
  
  METHODS
  Publications that described relevant cohort, case-control and cross-sectional studies were identified from in-house files, a Medline search in December 2005 and reference lists. Relative risks (RRs) and odds ratios (ORs) for ischaemic heart disease, stroke and all CID for ST use, stratified by smoking habit, were estimated and combined by meta-analysis to provide an overall RR estimate. For diabetes, increased blood pressure, and other risk factors, evidence was qualitatively reviewed, with results from clinical studies also considered.
  
  
  RESULTS
  ST use in non-smokers was associated with an increased risk of heart disease (RR 1.12, 95% CI 0.99-1.27, n = 8), stroke (1.42, 1.29-1.57, n = 5) and CID (1.25, 1.14-1.37, n = 3). The increases mainly derived from two large US studies. The Swedish studies provided little evidence of an increase for heart disease (1.06, 0.83-1.37, n = 5) or stroke (1.17, 0.80-1.70, n = 2), although the estimates by country are not notably heterogeneous, even for stroke (P = 0.29). No dose-response was evident. No increase was seen in former users of ST, or in ST users who also smoked. No clear relationship to diabetes was seen. In the US, an acute blood pressure rise following ST use was consistently reported, and isolated reports linked specific risk factors to ST. In Sweden, though one study reported that snuff acutely increased blood pressure, and two linked snuff to Raynaud-type symptoms, the overall evidence for an effect was inconclusive. Swedish studies generally showed no chronic effect of snuff on blood pressure or various risk factors.
  
  
  CONCLUSIONS
  Any CID risk from ST appears to be substantially less than from smoking, and no clear risk from Swedish snuff is seen. However, the overall evidence is limited.
authors.affiliation: PN Lee Statistics and Computing Ltd., 17 Cedar Road, Sutton, Surrey, SM2 5DA, UK. PeterLee@pnlee.co.uk
authors.forename: Peter N
authors.initials: PN
authors.lastname: Lee
mesh_terms: D002318:Cardiovascular Diseases / Q000209:etiology*; D016022:Case-Control Studies; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D006801:Humans; D016017:Odds Ratio; D018570:Risk Assessment / Q000379:methods; D014030:Tobacco, Smokeless / Q000009:adverse effects*