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Snus use and other correlates of smoking cessation in the Swedish Twin Registry

  • H. Furberg (a1), P. Lichtenstein (a2), N. L. Pedersen (a2) (a3), C. M. Bulik (a4), C. Lerman (a5) and P. F. Sullivan (a1) (a2)...

We investigated 12 variables and their interactions as correlates of smoking cessation among regular smokers in the population-based Swedish Twin Registry (STR).


Detailed information on tobacco use and personal characteristics were available from 14 715 male and female twins aged 42–64 years who participated in a screening of the population-based STR and reported being regular smokers in their lifetime. A two-stage analytic design was used to examine correlates of smoking cessation. The sample was split at random and significant main effects and interactions identified in the testing set were examined in the validation set. Hazard ratios (HRs) and 95% confidence intervals (CIs) describe the association between correlates and smoking cessation.


Twelve main effects were significantly associated with smoking cessation in the testing set; eight were confirmed in the validation set. Of the nine interactions identified in the testing set, none remained significant when evaluated in the validation set after Bonferroni correction. HRs were highest for Swedish oral smokeless tobacco (snus) use (HR 2.70, 95% CI 2.30–3.20), >11 years of education (HR 1.57, 95% CI 1.43–1.73) and being married or cohabitating (HR 1.51, 95% CI 1.39–1.63). Although not statistically significant after Bonferroni correction, snus use also appeared important in the context of interactions, where lower nicotine dependence score, higher socio-economic status (SES) and greater body size were associated with smoking cessation only among participants who never used snus.


Snus use was the strongest independent correlate of smoking cessation. Further studies should investigate the mechanism of this association.

Corresponding author
*Address for correspondence: Dr H. Furberg, Department of Genetics, CB#7264, 4109D Neurosciences Research Building, University of North Carolina, Chapel Hill, NC 27599-7264, USA. (Email:
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NA Accortt , JW Waterbor , C Beall , G Howard (2002). Chronic disease mortality in a cohort of smokeless tobacco users. American Journal of Epidemiology 156, 730737.

K Asplund (2003). Smokeless tobacco and cardiovascular disease. Progress in Cardiovascular Diseases 45, 383394.

K Asplund , S Nasic , U Janlert , B Stegmayr (2003). Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control study. Stroke 34, 17541759.

JE Audrain , RC Klesges , LM Klesges (1995). Relationship between obesity and the metabolic effects of smoking in women. Health Psychology 14, 116123.

G Bolinder , L Alfredsson , A Englund , U de Faire (1994). Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. American Journal of Public Health 84, 399404.

N Breslau , EO Johnson , E Hiripi , R Kessler (2001). Nicotine dependence in the United States: prevalence, trends, and smoking persistence. Archives of General Psychiatry 58, 810816.

M Curvall , L Romert , E Norlen , CR Enzell (1987). Mutagen levels in urine from snuff users, cigarette smokers and non tobacco users – a comparison. Mutation Research 188, 105110.

KO Fagerstrom , EB Schildt (2003). Should the European Union lift the ban on snus? Evidence from the Swedish experience. Addiction 98, 11911195.

KO Fagerstrom , NG Schneider (1989). Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. Journal of Behavioral Medicine 12, 159182.

E Fernandez , M Garcia , A Schiaffino , JM Borras , M Nebot , A Segura (2001). Smoking initiation and cessation by gender and educational level in Catalonia, Spain. Preventive Medicine 32, 218223.

J Foulds , L Kozlowski (2007). Snus – what should the public-health response be? Lancet 369, 19761978.

J Foulds , MB Steinberg , JM Williams , DM Ziedonis (2006). Developments in pharmacotherapy for tobacco dependence: past, present and future. Drug and Alcohol Review 25, 5971.

AH Furberg , C Bulik , P Lichtenstein , N Pedersen , PF Sullivan (2006). Patterns and prevalence of tobacco use in the Swedish Twin Registry. Addiction 101, 15091515.

N Gray (2005). Mixed feelings on snus. Lancet 366, 966967.

FE Harrell Jr., KL Lee , DB Mark (1996). Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Statistics in Medicine 15, 361387.

T Hastie , R Tibshiranti , J Friedman (2001). The Elements of Statistical Learning: Data Mining, Inference and Prediction. Springer: New York.

MP Hergens , A Ahlbom , T Andersson , G Pershagen (2005). Swedish moist snuff and myocardial infarction among men. Epidemiology 16, 1216.

F Huhtasaari , V Lundberg , M Eliasson , U Janlert , K Asplund (1999). Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men. Journal of the American College of Cardiology 34, 17841790.

E Janzon , G Engstrom , M Lindstrom , G Berglund , B Hedblad , L Janzon (2005). Who are the ‘quitters’? A cross-sectional study of circumstances associated with women giving up smoking. Scandinavian Journal of Public Health 33, 175182.

SE Johansson , K Sundquist , J Qvist , J Sundquist (2005). Smokeless tobacco and coronary heart disease: a 12-year follow-up study. European Journal of Cardiovascular Prevention and Rehabilitation 12, 387392.

J Lagergren , R Bergstrom , A Lindgren , O Nyren (2000). The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardia. International Journal of Cancer 85, 340346.

F Lewin , SE Norell , H Johansson , P Gustavsson , J Wennerberg , A Biorklund , LE Rutqvist (1998). Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer 82, 13671375.

MD Li , JK Kane , O Konu (2003). Nicotine, body weight and potential implications in the treatment of obesity. Current Topics in Medical Chemistry 3, 899919.

KY Liang , SL Zeger (1986). Longitudinal data analysis using general linear models. Biometrika 73, 1322.

P Lichtenstein , U De Faire , B Floderus , M Svartengren , P Svedberg , NL Pedersen (2002). The Swedish Twin Registry: a unique resource for clinical, epidemiological and genetic studies. Journal of Internal Medicine 252, 184205.

E Lunell , M Lunell (2005). Steady-state nicotine plasma levels following use of four different types of Swedish snus compared with 2-mg Nicorette chewing gum: a crossover study. Nicotine and Tobacco Research 7, 397403.

J Luo , W Ye , K Zendehdel , J Adami , HO Adami , P Boffetta , O Nyren (2007). Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet 369, 20152020.

M Osler , E Prescott , N Godtfredsen , HO Hein , P Schnohr (1999). Gender and determinants of smoking cessation: a longitudinal study. Preventive Medicine 29, 5762.

BG Osterdahl , C Jansson , A Paccou (2004). Decreased levels of tobacco-specific N-nitrosamines in moist snuff on the Swedish market. Journal of Agricultural and Food Chemistry 52, 50855088.

EM Perrin , KB Flower , AS Ammerman (2005). Pediatricians' own weight: self-perception, misclassification, and ease of counseling. Obesity Research 13, 326332.

PG Persson , S Carlsson , L Svanstrom , CG Ostenson , S Efendic , V Grill (2000). Cigarette smoking, oral moist snuff use and glucose intolerance. Journal of Internal Medicine 248, 103110.

A Radzius , JJ Gallo , DH Epstein , DA Gorelick , JL Cadet , GE Uhl , ET Moolchan (2003). A factor analysis of the Fagerstrom Test for Nicotine Dependence (FTND). Nicotine Tobacco Research 5, 255260.

L Ramstrom (2003 b). Snus: part of the problem or part of the solution? Addiction 98, 11981199; discussion 12041207.

LM Ramstrom , J Foulds (2006). Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 15, 210214.

B Rodu , C Jansson (2004). Smokeless tobacco and oral cancer: a review of the risks and determinants. Critical Reviews in Oral Biology and Medicine 15, 252263.

B Rodu , B Stegmayr , S Nasic , K Asplund (2002). Impact of smokeless tobacco use on smoking in northern Sweden. Journal of Internal Medicine 252, 398404.

B Rodu , B Stegmayr , S Nasic , P Cole , K Asplund (2004). The influence of smoking and smokeless tobacco use on weight amongst men. Journal of Internal Medicine 255, 102107.

KJ Rothman , S Greenland (1998). Modern Epidemiology. Lippincott-Raven: Philadelphia.

EB Schildt , M Eriksson , L Hardell , A Magnuson (1998). Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. International Journal of Cancer 77, 341346.

RA Schnoll , C Lerman (2006). Current and emerging pharmacotherapies for treating tobacco dependence. Expert Opinion in Emerging Drugs 11, 429444.

B Stegmayr , M Eliasson , B Rodu (2005). The decline of smoking in northern Sweden. Scandinavian Journal of Public Health 33, 321324; discussion 243.

W Ye , AM Ekstrom , LE Hansson , R Bergstrom , O Nyren (1999). Tobacco, alcohol and the risk of gastric cancer by sub-site and histologic type. International Journal of Cancer 83, 223229.

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Psychological Medicine
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