Skip to main content Accessibility help
×
Home

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)...

Abstract

Background

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

Method

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.

Results

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.

Conclusions

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

Copyright

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: helena_furberg@med.unc.edu)

References

Hide All
Accortt, NA, Waterbor, JW, Beall, C, Howard, G (2002). Chronic disease mortality in a cohort of smokeless tobacco users. American Journal of Epidemiology 156, 730737.
Allison, PD (1995). Survival Analysis Using the SAS System: A Practical Guide. SAS Institute, Inc.: Cary, NC.
APA (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn.American Psychiatric Press: Washington, DC.
Asplund, K (2003). Smokeless tobacco and cardiovascular disease. Progress in Cardiovascular Diseases 45, 383394.
Asplund, K, Nasic, S, Janlert, U, Stegmayr, B (2003). Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control study. Stroke 34, 17541759.
Audrain, JE, Klesges, RC, Klesges, LM (1995). Relationship between obesity and the metabolic effects of smoking in women. Health Psychology 14, 116123.
Bolinder, G, Alfredsson, L, Englund, A, de Faire, U (1994). Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. American Journal of Public Health 84, 399404.
Bonferroni, CE (1936). Statistical theory of classification and calculation of probabilities [in Italian]. Pubblicazioni del R Istituto Superiore di Scienze Economiche e Commerciali di Firenze 8, 362.
Breslau, N, Johnson, EO (2000). Predicting smoking cessation and major depression in nicotine-dependent smokers. American Journal of Public Health 90, 11221127.
Breslau, N, Johnson, EO, Hiripi, E, Kessler, R (2001). Nicotine dependence in the United States: prevalence, trends, and smoking persistence. Archives of General Psychiatry 58, 810816.
Broms, U, Silventoinen, K, Lahelma, E, Koskenvuo, M, Kaprio, J (2004). Smoking cessation by socioeconomic status and marital status: the contribution of smoking behavior and family background. Nicotine and Tobacco Research 6, 447455.
Cox, DR, Oakes, D (1984). Analysis of Survival Data. Chapman & Hall: London.
Curvall, M, Romert, L, Norlen, E, Enzell, CR (1987). Mutagen levels in urine from snuff users, cigarette smokers and non tobacco users – a comparison. Mutation Research 188, 105110.
Eliasson, M, Asplund, K, Nasic, S, Rodu, B (2004). Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study. Journal of Internal Medicine 256, 101110.
Evans, DM, Martin, NG (2000). The validity of twin studies. GeneScreen 1, 7779.
Fagerstrom, KO, Schildt, EB (2003). Should the European Union lift the ban on snus? Evidence from the Swedish experience. Addiction 98, 11911195.
Fagerstrom, KO, Schneider, NG (1989). Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. Journal of Behavioral Medicine 12, 159182.
Fernandez, E, Garcia, M, Schiaffino, A, Borras, JM, Nebot, M, Segura, A (2001). Smoking initiation and cessation by gender and educational level in Catalonia, Spain. Preventive Medicine 32, 218223.
Foulds, J, Kozlowski, L (2007). Snus – what should the public-health response be? Lancet 369, 19761978.
Foulds, J, Ramstrom, L, Burke, M, Fagerstrom, K (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control 12, 349359.
Foulds, J, Steinberg, MB, Williams, JM, Ziedonis, DM (2006). Developments in pharmacotherapy for tobacco dependence: past, present and future. Drug and Alcohol Review 25, 5971.
Furberg, AH, Bulik, C, Lichtenstein, P, Pedersen, N, Sullivan, PF (2006). Patterns and prevalence of tobacco use in the Swedish Twin Registry. Addiction 101, 15091515.
Furberg, H, Bulik, C, Lerman, C, Lichtenstein, P, Pedersen, N, Sullivan, P (2005). Is Swedish snus associated with smoking initiation or smoking cessation? Tobacco Control 14, 422424.
Gartner, CE, Hall, WD, Chapman, S, Freeman, B (2007). Should the health community promote smokeless tobacco (snus) as a harm reduction measure? Public Library of Science Medicine 4, e185.
Gilljam, H, Galanti, MR (2003). Role of snus (oral moist snuff ) in smoking cessation and smoking reduction in Sweden. Addiction 98, 11831189.
Ginzel, KH, Maritz, GS, Marks, DF, Neuberger, M, Pauly, JR, Polito, JR, Schulte-Hermann, R, Slotkin, TA (2007). Critical review: nicotine for the fetus, the infant and the adolescent? Journal of Health Psychology 12, 215224.
Gray, N (2005). Mixed feelings on snus. Lancet 366, 966967.
Haglund, B, Eliasson, M, Stenbeck, M, Rosen, M (2007). Is moist snuff use associated with excess risk of IHD or stroke? A longitudinal follow-up of snuff users in Sweden. Scandinavian Journal of Public Health 6, 15.
Harrell, FE Jr., Lee, KL, Mark, DB (1996). Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Statistics in Medicine 15, 361387.
Harrell, FE Jr., Lee, KL, Matchar, DB, Reichert, TA (1985). Regression models for prognostic prediction: advantages, problems, and suggested solutions. Cancer Treatment Reports 69, 10711077.
Hastie, T, Tibshiranti, R, Friedman, J (2001). The Elements of Statistical Learning: Data Mining, Inference and Prediction. Springer: New York.
Heatherton, TF, Kozlowski, LT, Frecker, RC, Fagerstrom, KO (1991). The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction 86, 11191127.
Hergens, MP, Ahlbom, A, Andersson, T, Pershagen, G (2005). Swedish moist snuff and myocardial infarction among men. Epidemiology 16, 1216.
Holm, H, Jarvis, MJ, Russell, MA, Feyerabend, C (1992). Nicotine intake and dependence in Swedish snuff takers. Psychopharmacology 108, 507511.
Huhtasaari, F, Asplund, K, Lundberg, V, Stegmayr, B, Wester, PO (1992). Tobacco and myocardial infarction: is snuff less dangerous than cigarettes? British Medical Journal 305, 12521256.
Huhtasaari, F, Lundberg, V, Eliasson, M, Janlert, U, Asplund, K (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.
Hyland, A, Li, Q, Bauer, JE, Giovino, GA, Steger, C, Cummings, KM (2004). Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine and Tobacco Research 6 (Suppl. 3), S363S369.
Janzon, E, Engstrom, G, Lindstrom, M, Berglund, G, Hedblad, B, Janzon, L (2005). Who are the ‘quitters’? A cross-sectional study of circumstances associated with women giving up smoking. Scandinavian Journal of Public Health 33, 175182.
Johansson, SE, Sundquist, K, Qvist, J, Sundquist, J (2005). Smokeless tobacco and coronary heart disease: a 12-year follow-up study. European Journal of Cardiovascular Prevention and Rehabilitation 12, 387392.
Kaprio, J, Koskenvuo, M (1988). A prospective study of psychological and socioeconomic characteristics, health behavior and morbidity in cigarette smokers prior to quitting compared to persistent smokers and non-smokers. Journal of Clinical Epidemiology 41, 139150.
Lagergren, J, Bergstrom, R, Lindgren, A, Nyren, O (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.
Lambe, M (2004). Tobacco control, ethics and Swedish snus. Acta Oncologica 43, 34.
Lambe, M (2007). Swedish snus for tobacco harm reduction. Lancet 370, 1206.
Lee, PN (2007). Circulatory disease and smokeless tobacco in Western populations: a review of the evidence. International Journal of Epidemiology 36, 789804.
Levy, DT, Mumford, EA, Cummings, KM, Gilpin, EA, Giovino, GA, Hyland, A, Sweanor, D, Warner, KE, Compton, C (2006). The potential impact of a low-nitrosamine smokeless tobacco product on cigarette smoking in the United States: estimates of a panel of experts. Addictive Behaviors 31, 11901200.
Lewin, F, Norell, SE, Johansson, H, Gustavsson, P, Wennerberg, J, Biorklund, A, Rutqvist, LE (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.
Li, MD, Kane, JK, Konu, O (2003). Nicotine, body weight and potential implications in the treatment of obesity. Current Topics in Medical Chemistry 3, 899919.
Liang, KY, Zeger, SL (1986). Longitudinal data analysis using general linear models. Biometrika 73, 1322.
Lichtenstein, P, De Faire, U, Floderus, B, Svartengren, M, Svedberg, P, Pedersen, NL (2002). The Swedish Twin Registry: a unique resource for clinical, epidemiological and genetic studies. Journal of Internal Medicine 252, 184205.
Lichtenstein, P, Sullivan, PF, Cnattingius, S, Gatz, M, Johansson, S, Carlstrom, E, Bjork, C, Svartengren, M, Wolk, A, Klareskog, L, de Faire, U, Schalling, M, Palmgren, J, Pedersen, NL (2006). The Swedish Twin Registry in the third millennium: an update. Twin Research and Human Genetics 9, 875882.
Lindstrom, M, Isacsson, SO (2002). Smoking cessation among daily smokers, aged 45–69 years: a longitudinal study in Malmo, Sweden. Addiction 97, 205215.
Lunell, E, Lunell, M (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.
Luo, J, Ye, W, Zendehdel, K, Adami, J, Adami, HO, Boffetta, P, Nyren, O (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.
McKee, M, Gilmore, A (2007). Swedish snus for tobacco harm reduction. Lancet 370, 1206.
Norberg, M, Stenlund, H, Lindahl, B, Boman, K, Weinehall, L (2006). Contribution of Swedish moist snuff to the metabolic syndrome: a wolf in sheep's clothing? Scandinavian Journal of Public Health 34, 576583.
Novak, M, Ahlgren, C, Hammarstrom, A (2006). A life-course approach in explaining social inequity in obesity among young adult men and women. International Journal of Obesity (London) 30, 191200.
Osler, M, Prescott, E, Godtfredsen, N, Hein, HO, Schnohr, P (1999). Gender and determinants of smoking cessation: a longitudinal study. Preventive Medicine 29, 5762.
Osterdahl, BG, Jansson, C, Paccou, A (2004). Decreased levels of tobacco-specific N-nitrosamines in moist snuff on the Swedish market. Journal of Agricultural and Food Chemistry 52, 50855088.
Pedersen, NL, Lichtenstein, P, Svedberg, P (2002). The Swedish Twin Registry in the third millennium. Twin Research 5, 427432.
Perrin, EM, Flower, KB, Ammerman, AS (2005). Pediatricians' own weight: self-perception, misclassification, and ease of counseling. Obesity Research 13, 326332.
Persson, PG, Carlsson, S, Svanstrom, L, Ostenson, CG, Efendic, S, Grill, V (2000). Cigarette smoking, oral moist snuff use and glucose intolerance. Journal of Internal Medicine 248, 103110.
Radzius, A, Gallo, JJ, Epstein, DH, Gorelick, DA, Cadet, JL, Uhl, GE, Moolchan, ET (2003). A factor analysis of the Fagerstrom Test for Nicotine Dependence (FTND). Nicotine Tobacco Research 5, 255260.
Ramstrom, L (2000). Snuff – an alternative nicotine delivery system. In Nicotine and Public Health (ed. Ferrence, R.), pp. 159178. American Public Health Association: Washington, DC.
Ramstrom, L (2003 a). Patterns of use: a gate leading to smoking or a way out? Nicotine and Tobacco Research 5, 268.
Ramstrom, L (2003 b). Snus: part of the problem or part of the solution? Addiction 98, 11981199; discussion 12041207.
Ramstrom, LM, Foulds, J (2006). Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 15, 210214.
Rodu, B, Jansson, C (2004). Smokeless tobacco and oral cancer: a review of the risks and determinants. Critical Reviews in Oral Biology and Medicine 15, 252263.
Rodu, B, Stegmayr, B, Nasic, S, Asplund, K (2002). Impact of smokeless tobacco use on smoking in northern Sweden. Journal of Internal Medicine 252, 398404.
Rodu, B, Stegmayr, B, Nasic, S, Cole, P, Asplund, K (2003). Evolving patterns of tobacco use in northern Sweden. Journal of Internal Medicine 253, 660665.
Rodu, B, Stegmayr, B, Nasic, S, Cole, P, Asplund, K (2004). The influence of smoking and smokeless tobacco use on weight amongst men. Journal of Internal Medicine 255, 102107.
Rothman, KJ, Greenland, S (1998). Modern Epidemiology. Lippincott-Raven: Philadelphia.
SAS Institute (2004). SAS/STAT Software: Version 9. SAS Institute, Inc.: Cary, NC.
Savitz, DA, Meyer, RE, Tanzer, JM, Mirvish, SS, Lewin, F (2006). Public health implications of smokeless tobacco use as a harm reduction strategy. American Journal of Public Health 96, 19341939.
Schildt, EB, Eriksson, M, Hardell, L, Magnuson, A (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.
Schnoll, RA, Lerman, C (2006). Current and emerging pharmacotherapies for treating tobacco dependence. Expert Opinion in Emerging Drugs 11, 429444.
Shtatland, ES, Cain, E, Barton, MB (2001). The perils of stepwise logistic regression and how to escape them using information criteria and the output delivery system. In Proceedings of the 26th Annual SAS Users Group International Conference, Long Beach, CA, 22–25 April 2001. Paper 222–26. SAS Institute Inc.: Cary, NC.
Silagy, C, Lancaster, T, Stead, L, Mant, D, Fowler, G (2004). Nicotine replacement therapy for smoking cessation. Cochrane Database System Review, CD000146.
Statistics, Sweden (1983). Socioekonomisk indelning (SEI). Meddelande i samordningsfragor 1982: 4 (Swedish Socio-economic Classification). Statistics Sweden: Stockholm.
Stegmayr, B, Eliasson, M, Rodu, B (2005). The decline of smoking in northern Sweden. Scandinavian Journal of Public Health 33, 321324; discussion 243.
van Loon, AJ, Tijhuis, M, Surtees, PG, Ormel, J (2005). Determinants of smoking status: cross-sectional data on smoking initiation and cessation. European Journal of Public Health 15, 256261.
WHO (1998). Obesity: Preventing and Managing the Global Epidemic. Report of a WHO consultation on obesity. World Health Organization: Geneva.
Ye, W, Ekstrom, AM, Hansson, LE, Bergstrom, R, Nyren, O (1999). Tobacco, alcohol and the risk of gastric cancer by sub-site and histologic type. International Journal of Cancer 83, 223229.

Keywords

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)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed