Smokeless-tobacco use hints at higher death rates post-MI

Continued use of a smokeless tobacco called snus—often considered a safer alternative to cigarettes and used by those trying to stop smoking—is associated with an increased risk of death in those who have already suffered a heart attack, new research from Sweden shows.
"Every time we discharge an MI patient who's a snus user, we are faced with the clinically important question of whether they should discontinue use," researcher Dr Gabriel Arefalk (Uppsala University, Sweden) told a press conference today here at the European Society of Cardiology 2011 Congress.

And although the results of his observational study were not significant after extensive multivariate adjustment—so cannot really be used by doctors to advise patients to stop using snus—he said the totality of the evidence points to snus being harmful, including a meta-analysis published in BMJ in 2009 [1], as previously reported by heartwire. The American Heart Association agrees, he adds, having advised against its use.

Nevertheless, the effects of quitting snus post-MI should ideally still be studied in a randomized clinical trial to confirm his findings, Arefalk said.
Arefalk explained that snus—which comes in the form of small sachets (like mini tea bags) or as a loose tobacco powder placed as a bolus under the upper lip for around an hour—has increasingly been used by people in Sweden to try to quit smoking. Use has increased in the past two decades, he said, and has now reached a plateau—around 20% of men and 4% of women use it.

Although smoking is undoubtedly more harmful than snus use and "there is no doubt that if you have to choose between smoking cigarettes and snus use that the latter is less harmful," he says, experimental evidence indicates that the nicotine in snus induces acute hemodynamic effects such as increased blood pressure and heart rate.

Because no study has addressed the question of whether snus users who have had an MI are at increased risk of further events or death if they continue to use the smokeless tobacco, Arefalk and colleagues decided to investigate this important clinical question.

They followed 20 911 consecutive MI patients under aged 75 or less admitted to a coronary care unit in Sweden between 2005 and 2009. Two months after discharge, patients were asked about traditional CV risk factors, including past and present tobacco exposure, snus use, and whether they participated in rehab programs.