Discontinuation of Smokeless Tobacco and Mortality Risk After Myocardial Infarction

Study Questions:

Does discontinuation of snus (oral moist snuff wrapped in a tiny tea bag) use after a myocardial infarction (MI) reduce mortality risk?


All patients who were admitted to coronary care units for an MI in Sweden between 2005 and 2009 and were under the age of 75 underwent a structured examination 2 months post-discharge (the baseline of the present study). The risk of mortality in post-MI snus quitters (n = 675) relative to post-MI continuous snus users (n = 1,799) was compared using Cox proportional hazards analyses.


During follow-up (mean 2.1 years), 83 participants died. The mortality rate in post-MI snus quitters was 9.7 (95% confidence interval [CI], 5.7-16.3)/1,000 person-years-at-risk and in post-MI continuous snus users 18.7 (95% CI, 14.8-23.6)/1,000 person-years-at-risk. Adjusting for age and gender, post-MI snus quitters had half the mortality risk of post-MI continuous snus users (hazard ratio, 0.51; 95% CI, 0.29-0.91). In a multivariable-adjusted model, the hazard ratio was 0.57 (95% CI, 0.32-1.02). The corresponding estimate for post-MI smoke quitters versus post-MI continuous smokers was 0.54 (95% CI, 0.42-0.69).


Discontinuation of snus use post-MI was associated with a nearly halved mortality risk, similar to the benefit associated with smoking cessation. These observations suggest that the use of snus post-MI should be discouraged.


Snus (pronounced snoose and produced in Sweden and banned in most of Europe) is gaining popularity in the United States as a smokeless tobacco. It is high in nicotine, but is said to be lower in carcinogens. This very important study demonstrates the hazard of nicotine post-MI that is independent of the inhaled micro particles, and should be a warning to snuff users. The findings are in conflict with previous studies that concluded snus is the least harmful of the smokeless tobacco products and that there is a 95-99% reduction in health risk compared to cigarettes.

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