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Epidemiology. 2014 Nov;25(6):872-6. doi: 10.1097/EDE.0000000000000169.

Use of Scandinavian moist smokeless tobacco (snus) and the risk of atrial fibrillation.

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  • 1From the aDepartment of Communicable Disease Control, Stockholm County Council, Stockholm, Sweden; bDepartment of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; cCentre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden; dInstitute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; eDepartment of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; fDepartment of Statistics, University of Milano-Bicocca, Milano, Italy; gDepartment of Statistics, Umeå University, Umeå, Sweden; hSchool of Health Science, Jönköping University, Jönköping, Sweden; iDepartment of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; jDepartment of Medicine, Umeå University, Umeå, Sweden; kDepartment of Health Sciences, Mid Sweden University, Sundsvall, Sweden; lUnit of Clinical Epidemiology, Dept of Medicine, Karolinska Institutet, Stockholm, Sweden; and mSocial Medicine and Global Health, Department of Clinical Sciences In Malmö, Lund University, Lund, Sweden.



Snus is a smokeless tobacco product, widely used among Swedish men and increasingly so elsewhere. There is debate as to whether snus is an acceptable "harm-reduction" tobacco product. Since snus use delivers a dose of nicotine equivalent to cigarettes, and has been implicated in cardiac arrhythmia because of associations with sudden cardiovascular death, a relation with atrial fibrillation is plausible and important to investigate.


To assess the relation between use of snus and risk of atrial fibrillation, we carried out a pooled analysis of 7 prospective Swedish cohort studies. In total, 274,882 men, recruited between 1978 and 2004, were followed via the National Patient Register for atrial fibrillation. Primary analyses were restricted to 127,907 never-smokers. Relative risks were estimated using Cox proportional hazard regression.


The prevalence of snus use was 25% among never-smokers. During follow-up, 3,069 cases of atrial fibrillation were identified. The pooled relative risk of atrial fibrillation was 1.07 (95% confidence interval = 0.97-1.19) in current snus users, compared with nonusers.


Findings from this large national pooling project indicate that snus use is unlikely to confer any important increase in risk of atrial fibrillation.

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