The SCAPIS-Snus Study

In Sweden, the number of snus users has remained very stable for many years, with roughly 20 percent of men and approximately 4-5 percent of women classified as users. However, since the introduction of "white snus," usage has increased explosively among women, who now use snus at nearly the same rate as men. Once again, the youngest age groups account for this increase.

Snus use has also gained increasing international popularity. In the US, where Swedish-style portion snus was legalized in 2011, and snus is intensively marketed as an alternative to smoking.

Snus has long been considered a relatively risk-free alternative to tobacco smoking. However, snus users experience increased mortality associated with myocardial infarction and stroke, and studies have shown that mortality in patients with a previous myocardial infarction is halved among those who quit using snus after the infarction compared to those who continue. In experimental studies, investigators demonstrated that snus users who have used snus for more than 15 years exhibit increased arterial stiffness and respond more poorly to nitroglycerin. Other studies, however, have not demonstrated any association between snus use and coronary artery disease. These divergent results indicate that further research is needed to determine whether a genuine link exists between snus use and cardiovascular disease.

The objective is to investigate whether snus use is associated with: An increased degree of atherosclerosis and plaque formation on coronary computed tomography angiography (CCTA/CAC). Elevated cardiometabolic markers associated with an increased risk of cardiovascular diseases (NT-ProBNP, troponins, lipids, glucose, blood pressure, ankle pressure, waist circumference, weight, OGTT) Mental illness, stress, and sick leave.

Additionally, the objective is to explore how changes in snus use between SCAPIS 1 and 2 affect the progression of these factors.

Hypothesis: Snus use, independent of smoking, is associated with increased atherosclerosis and its complications, higher blood pressure, a poorer metabolic profile, and increased stress burden.

Data Material and Study Design:

Data Source: SCAPIS 1 (baseline) and SCAPIS 2 (follow-up).

Design:

Cross-sectional analysis (SCAPIS 1):

Exposure: snus; Outcome: CCTA/CAC, cardiometabolic markers, and mental illness.

Longitudinal analysis (SCAPIS 1→2):

Exposure: change in snus use; Outcome: progression of atherosclerosis, metabolic, and mental health outcomes

Study Sample:

Participants with data on tobacco use, CCTA/CAC, blood pressure, metabolic markers, mental health, and stress. Individuals with known CVD will be excluded.

Cohort Size: Over 30,000 men and women. Locations: Recruited across six Swedish university hospitals: Gothenburg, Malmö/Lund, Linköping, Stockholm, Umeå, and Uppsala.

Inclusion criteria

• Age 50-64 years at the time of inclusion
• Selection: Randomly selected from the Swedish national population register.