Patterns and Determinants of Exclusive Smokeless Tobacco (Snus) Use, Exclusive Smoking and Dual Use in General Population During 20 Years.

BACKGROUND: We investigate smokeless tobacco (snus) use and its correlates over 20 years in a country where selling snus is prohibited but a large import quota and illicit market exists. METHODS: Repeated cross-sectional population-based surveys during 2000 to 2020 in Finland, including N = 57 111 adults aged 20 to 64 years. The outcome measures were current tobacco use (exclusive snus use, dual use, exclusive smoking, no tobacco use) and snus use (daily, occasional, no snus use). Study years, gender, age, education, marital status, self-rated health, body mass index, and binge drinking were used as explanatory variables. RESULTS: Exclusive snus use and dual use increased 3.6% units and 2.6% units from 2000 to 2005 and from 2018 to 2020, respectively. Overall decrease of tobacco use was led by decreasing exclusive smoking from 30.1% to 18.2%. The shared risk factors for snus use and dual use were male gender, age group 20 to 34 years, and binge drinking. The increases in snus and dual use over time were also most prevalent among these groups. Among men, occasional smoking increased the likelihood of daily (relative risk ratio [RRR] 2.38, 95% confidence interval [CI] 1.42, 3.99) and occasional (RRR 3.11, 95% CI 1.93, 5.03) snus use. CONCLUSIONS: Snus use has increased among the general adult population in Finland during 2000 to 2020 yet remains less common than smoking. Snus use and dual use share some common risk factors. Snus use should be considered in cessation services, with support for quitting developed and targeted predominantly for men, younger adults, and persons drinking to intoxication.

Nicotine pouch use by sex, school type and tobacco product use among Finnish adolescents during the 2023 change in regulatory scheme with deregulated sales.

BACKGROUND AND AIMS: In Finland, nicotine pouches entered the national market abruptly in 2023, following a change in April 2023 from medicinal product classification into less regulated tobacco surrogate status. This study aimed to measure adolescent nicotine pouch use and associated characteristics. DESIGN AND SETTING: A cross-sectional, nationwide school-based survey among students in comprehensive schools (COMP), general upper secondary schools (GEN) and vocational institutes (VOC) in 2023 in Finland. PARTICIPANTS: A total of 151 224 respondents aged 14-20 years (mean age 16.18 years, standard deviation 1.20 years). MEASUREMENTS: Nicotine pouch use was used as the outcome variable. Demographics included age, sex, school type and tobacco product use (smoking, snus use and e-cigarette use). Covariates included parental education and parental smoking. All measures were self-reported. FINDINGS: Unadjusted results showed that current nicotine pouch use was more common among boys (11.3%) than among girls (3.3%), adolescents in VOC (15.4%) compared with COMP (6.8%) and GEN (4.3%), whereas daily use of other tobacco and nicotine products was associated with current nicotine pouch use compared with never using such products and the association was especially strong for snus use. The fully adjusted estimates of current nicotine pouch use remained strong for daily use of other tobacco and nicotine products (snus use: adjusted prevalence ratio [aPR] = 74.95, 95% confidence interval [CI] = 65.65-84.25; smoking: aPR = 1.43, 95% CI = 1.36-1.50; e-cigarette use: aPR = 2.15, 95% CI = 2.04-2.27) and for sex (boys aPR = 1.53, 95% CI = 1.48-1.57). There was no clear evidence of differences in current nicotine pouch use by school type, age or parental factors in the fully adjusted model. CONCLUSIONS: In Finland in 2023, during which the availability of nicotine pouches became less regulated, nicotine pouch use appeared to be more common among boys and adolescents who used other nicotine products.

Self-assembled core-shell nanoparticles with embedded internal standards for SERS quantitative detection and identification of nicotine released from snus products.

Surface enhanced Raman spectroscopy (SERS) is a unique analytical technique with excellent performance in terms of sensitivity, non-destructive detection and resolution. However, due to the randomness and poor repeatability of hot spot distribution, SERS quantitative analysis is still challenging. Meanwhile, snus is a type of tobacco product that can release nicotine and other components in the mouth without burning, and the rapid detection technique based on SERS can reliably evaluate the amount of nicotine released from snus, which is of great significance for understanding its characteristics and regulating its components. Herein, the strategy was proposed to solve the feasibility of SERS quantitative detection based on self-assembled core-shell nanoparticles with embedded internal standards (EIS) due to EIS signal can effectively correct SERS signal fluctuations caused by different aggregation states and measurement conditions, thus allowing reliable quantitative SERS analysis of targets with different surface affinity. By means of process control, after the Au nanoparticles (Au NPs) were modified with 4-Mercaptobenzonitrile (4-MBN) as internal standard molecules, Ag shell with a certain thickness was grown on the surface of the AuNP@4-MBN, and then the Au@4-MBN@Ag NPs were used to regulate and control the assembly of liquid-liquid interface. The high-density nano-arrays assembled at the liquid-liquid interface ensure high reproducibility as SERS substrates, and which could be used for SERS detection of nicotine released from snus products. In addition, time-mapping research shows that this method can also be used to dynamically monitor the release of nicotine. Moreover, such destruction-free evaluation of the release of nicotine from snus products opens up new perspectives for further research about the impact of nicotinoids-related health programs.

Multi-endpoint in vitro toxicological assessment of snus and tobacco-free nicotine pouch extracts.

'Modern' oral tobacco-free nicotine pouches (NPs) are a nicotine containing product similar in appearance and concept to Swedish snus. A three-step approach was taken to analyse the biological effects of NPs and snus extracts in vitro. ToxTracker was used to screen for biomarkers for oxidative stress, cell stress, protein damage and DNA damage. Cytotoxicity, mutagenicity, and genotoxicity were assessed in the following respective assays: Neutral Red Uptake (NRU), Ames and Mouse Lymphoma Assay (MLA). Targeted analysis of phosphorylation signalling and inflammatory markers under non-toxic conditions was used to investigate any potential signalling pathways or inflammatory response. A reference snus (CRP1.1) and four NPs with various flavours and nicotine strengths were assessed. Test article extracts was generated by incubating one pouch in 20 mL of media (specific to each assay) with the inclusion of the pouch material. NP extracts did not induce any cytotoxicity or mutagenic response, genotoxic response was minimal and limited signalling or inflammatory markers were induced. In contrast, CRP1.1 induced a positive response in four toxicological endpoints in the absence of S9: Srxn1 (oxidative stress), Btg2 (cell stress), Ddit3 (protein damage) and Rtkn (DNA damage), and three endpoints in presence of S9: Srxn1, Ddit3 and Rtkn. CRP1.1 was genotoxic when assessed in MLA and activated signalling pathways involved in proliferation and cellular stress and specifically induced phosphorylation of c-JUN, CREB1, p53, p38 MAPK and to a lesser extent AKT1S1, GSK3α/ß, ERK1/2 and RSK1 in a dose-dependent manner. CRP 1.1 extracts resulted in the release of several inflammatory mediators including cytokines IL-1α, IL5, IL6, IL8, IL-1RA, MIF and TNF-ß, receptor IL-2RA, and growth factors FGF-basic, VEGF and M-CSF. In conclusion these assays contribute to the weight of evidence assessment of the potential comparative health risks of NPs and snus.

Arterial Stiffness and Carotid Intima-Media Thickness in Children Exposed to Smokeless Tobacco in Fetal Life.

BACKGROUND: Arterial stiffening and increased intima-media thickness can be seen as early as childhood and are associated with increased risk of cardiovascular events in adult life. The authors hypothesized that exposure to prenatal smokeless tobacco (Swedish snus) without additional nicotine exposure after the breastfeeding period would be associated with increased arterial stiffness and intima-media thickening in preschool children. METHODS AND RESULTS: This was a longitudinal follow-up cohort study of children aged 5 to 6 years exposed to high doses of nicotine in utero. Women exclusively using snus and unexposed controls were enrolled in early pregnancy (gestational age range, 6-12 weeks). Exposure data were collected during and after pregnancy with questionnaires from both groups. For this study, only children of women using >48 mg nicotine per day during their entire pregnancy were included in the exposure group. Outcomes were determined in 40 healthy children (21 exposed to snus in utero). Ultrasonography of the common carotid artery was used to determine carotid intima-media thickness and calculate arterial stiffness index from the relationship between pulsatile changes in arterial diameter and arterial pressure. Children exposed to snus in fetal life had higher carotid stiffness (median 4.1 [interquartile range (IQR), 2.4-5] versus 2.9 [IQR, 2.1-3.5]; P=0.014) than tobacco-free controls. Carotid strain (relative diameter change) was lower in children exposed to snus (mean 16% [SD, 5.7%] versus 21% [SD, 6.6%]) than in controls (P=0.015). Carotid intima-media thickness did not differ significantly between children exposed to snus and controls. CONCLUSIONS: Exposure to snus during fetal life was associated with a stiffer carotid artery in preschool children.

The Association Between Tobacco Use and Risk of COVID-19 Infection and Clinical Outcomes in Sweden: A Population-Based Study.

Background: The association between tobacco use and COVID-19 is controversial. During the early course of the pandemic, limited testing prevented studying a wide spectrum of clinical manifestations. Objective: To examine the potential causal association between tobacco use and COVID-19 during the second wave (1 October 2020-30 June 2021) of the pandemic in Stockholm, Sweden. Methods: A population-based cohort study was conducted in the Stockholm region of Sweden, with information on tobacco use collected prior to the pandemic. Adjusted relative risks (RR) of COVID-19 and 95% confidence intervals (CI) were calculated, contrasting current smokers and snus users to non-users of tobacco. Results: Compared with non-users of tobacco, current smokers had a lower risk of COVID-19 (RR 0.78, 95% CI = 0.75-0.81) and of hospitalisation for the disease. Current snus users had a higher risk of COVID-19. Heavy smokers and snus users had longer hospital stays than non-users of tobacco. Conclusion: Tobacco use may have a different impact on the risk of being infected with SARS-CoV-2 and the risk of developing severe clinical manifestations. Further research is needed to determine the underlying mechanisms.

Effects of reduced-risk nicotine-delivery products on smoking prevalence and cigarette sales: an observational study.

Background: It is not currently clear what impact alternative nicotine-delivery products (electronic cigarettes, heated tobacco products and snus) have on smoking rates and cigarette sales. Objective: To assess whether access to these products promotes smoking in the population. Design and data sources: We examined associations of alternative nicotine product use and sales with smoking rates and cigarette sales overall, and in different age and socioeconomic groups, and compared smoking prevalence over time in countries with contrasting regulations of these products. For electronic cigarettes, we examined data from countries with historically similar smoking trajectories but differing current electronic cigarette regulations (United Kingdom and United States of America vs. Australia, where sales of nicotine-containing electronic cigarettes are banned); for heated tobacco, we used data from countries with state tobacco monopolies, where cigarette and heated tobacco sales data are available (Japan, South Korea), and for snus we used data from Sweden. Analysis methods: We pre-specified dynamic time series analyses to explore associations between use and sales of alternative nicotine-delivery products and smoking prevalence and cigarette sales, and time series analyses to compare trends of smoking prevalence in countries with different nicotine product policies. Results: Because of data and analysis limitations (see below), results are only tentative and need to be interpreted with caution. Only a few findings reached statistical significance and for most results the Bayes factor indicated inconclusive evidence. We did not find an association between rates of smoking and rates of the use of alternative nicotine products. The increase in heated tobacco product sales in Japan was accompanied by a decrease in cigarette sales. The decline in smoking prevalence seems to have been slower in Australia than in the United Kingdom overall, and slower than in both the United Kingdom and the United States of America among young people and also in lower socioeconomic groups. The decline in cigarette sales has also accelerated faster in the United Kingdom than in Australia. Limitations: Most of the available data had insufficient data points for robust time series analyses. The assumption of our statistical approach that causal interactions are more likely to be detected when longer-term changes are screened out may not apply for short time series and in product interaction scenarios, where short-term fluctuations can be caused by, for example, fluctuations in prosperity or product supplies. In addition, due to dual use, prevalence figures for smoking and alternative product use overlap. The ecological study design limits the causal inferences that can be made. Longer time periods are needed for any effects of exclusive use of the new products on smoking prevalence to emerge. Conclusions: We detected some indications that alternative nicotine products are competing with cigarettes rather than promoting smoking and that regulations that allow their sales are associated with a reduction rather than an increase of smoking, but the findings are inconclusive because of insufficient data points and issues with the assumptions of the pre-specified statistical analyses. Future work: As further prevalence and sales data emerge the analyses will become more informative. Accessing sales figures in particular is the current research priority. Study registration: The project is registered on Open Science Framework https://osf.io/bd3ah. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR129968) and will be published in full in Public Health Research; Vol. 11, No. 7. See the NIHR Journals Library website for further project information.

Alternative nicotine-delivery products are now available which are much less hazardous than cigarettes. These include electronic cigarettes (which contain no tobacco), Swedish snus (oral tobacco with low levels of cancer-causing chemicals) and heated tobacco products. There is concern that these products attract young people to smoking and discourage smokers from quitting (i.e. increase smoking), but it is also possible that they help smokers quit and steer young people who find nicotine attractive away from smoking, or that they have no effect on smoking. To clarify which of these end results is likely, we looked at data on smoking and on the use of these alternative products over time, and also compared data on smoking from countries that have similar tobacco control history, but that either allow (i.e. United Kingdom and United States of America) or ban the sale of electronic cigarettes (i.e. Australia). As the sale of heated tobacco products increased in Japan, sales of cigarettes seem to have gone down, suggesting that this product is competing with cigarettes rather than encouraging their use. We also found that the drop in smoking may have been slower in Australia than in the United Kingdom. For young people and those on low income specifically, the reduction in smoking was slower in Australia than in both the United Kingdom and United States of America. Allowing alternative nicotine products to be sold seems to have been linked with lowered rather than increased rates of smoking. Our findings, however, are uncertain because only limited data were available. Clearer conclusions will become possible as more data on the use and especially on the sales of alternative nicotine products are collected.

Dietary habits among snus users: a population-based cross-sectional study.

Background: The dietary habits among snus users are largely unknown and have not been accounted for in observational studies on the health effects of snus use. Aim: To examine whether snus users eat unhealthier than never tobacco users. Methods: A total of 3,397 male participants, examined between 1994 and 2014 in the Northern Sweden Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, were included. Snus use and dietary habits were self-reported using questionnaires, from which intakes of different food groups, macronutrients, and a healthy diet score (HDS) were calculated (the latter as a proxy for overall diet quality). The association between snus use and dietary habits was examined by quantile regression models. Results: In the multivariable-adjusted model, current snus users had a lower HDS (median difference: -0.86 [95% confidence interval: -1.32, -0.40]) than never tobacco users. Snus users also consumed fewer weekly servings of fruits and berries (median difference: -1.03 [-1.65, -0.40]), and their estimated percentage of energy intake consisted of less carbohydrates (median difference: -1.43 [-2.12, -0.74]) and of more total fat (median difference: 0.99 [0.30, 1.67]), saturated fat (median difference: 0.67 [0.29, 1.05]), monounsaturated fat (median difference: 0.44 [0.20, 0.68]), trans fat (median difference: 0.03 [0.01, 0.06]), and alcohol (median difference: 0.21 [0.02, 0.40]). Conclusion: We observed that snus users had an unhealthier diet than never tobacco users. Future studies on the association between snus use and health outcomes should, therefore, consider diet as a potential confounder.

A systematic review of cancer risk among users of smokeless tobacco (Swedish snus) exclusively, compared with no use of tobacco.

The main objective of this systematic review was to assess cancer risk, and mortality after cancer diagnosis, for exclusive users of Swedish snus, compared with non-users of tobacco. We followed international standards for systematic reviews and graded our confidence in the risk estimates using the GRADE approach. Our search gave 2450 articles, of which 67 were assessed in full text against our inclusion criteria. Of these, 14 cohort-studies and one case-control study were included in the review. The studies investigated risk of cancer in the oral cavity or oropharynx (3 studies), esophagus (1 study), stomach (1 study), pancreas (2 studies), colorectum (2 studies), anus (1 study) and lung (1 study), as well as malignant lymphoma (1 study), leukemia and multiple myeloma (1 study), melanoma (1 study), any cancer (1 study) and mortality after cancer diagnosis (4 studies). Cancer risk could only be evaluated in men as there was a general lack of data for women. All included studies were evaluated to have a moderate risk of bias, mostly related to validity of exposure information. An increased risk of cancer of the esophagus, pancreas, stomach and rectum as well as an association between use of snus and increased mortality after a cancer diagnosis was reported. Our confidence in the various risk estimates varied from moderate through low to very low.

Erratum: Use of tobacco, nicotine and cannabis products among students in Switzerland.

[This corrects the article DOI: 10.3389/fpubh.2023.1076217.].

Use of tobacco, nicotine and cannabis products among students in Switzerland.

Introduction: Most people who smoke cigarettes begin in their teens and teens may also be attracted to new tobacco, nicotine, and cannabis products. We describe use prevalence among upper-secondary school students in Switzerland, including daily use, of tobacco, nicotine, and cannabis products. Methods: We invited secondary school students (age 15 to 21) in two Swiss cantons to take an online survey between October 2021 and February 2022. The survey collected demographic information and asked how frequently they used tobacco products (cigarettes in commercial packages, self-rolled cigarettes, hookahs, pipes, cigars and cigarillos, tobacco heating systems, snus, snuff), non-tobacco nicotine products (nicotine pouches, e-cigarettes with and without nicotine), and cannabis products (smoking with and without tobacco, cannabis vaping). Answers were scored on a Likert scale (no use in past month, less than weekly, weekly but not daily, daily use, prefer not to say), then tabulated and reported as descriptive statistics. Results: Of 32,614 students in the schools we contacted, 9,515 (29.2%) completed the survey; 49.5% identified as female and 48.4% as male; 9.5% were under 16, 47% were 16-17, 27.5% were 18-19, and 16% were over 19. Reported daily use was most frequent for tobacco cigarettes in commercial packages (14.2%), snus (4.1%) and cannabis smoking with tobacco (3.6%). Most participants (54.8%) reported they had used at least one product at least once within the last month. Conclusion: Students who used a product were most likely to smoke cigarettes, but many regularly used new tobacco, nicotine and cannabis products, though use frequency varies.

Association between snus use and lipid status in Swedish men.

Snus is a common tobacco product in Sweden, but the cardiovascular risk profile for snus users is less known than for cigarette smokers. We examined the association of snus use with lipid status, particularly in comparison to non-tobacco use and cigarette smoking, using data from 5930 men in the Northern Sweden MONICA study. Tobacco use was self-reported in 1986 to 2014 (24.4% used snus) and blood samples were collected at the same time. Harmonized analyses on non-high-density lipoprotein (non-HDL) cholesterol, HDL cholesterol, and triglycerides were conducted in 2016 to 2018. Three hundred eighty-one snus users had also been examined more than once, allowing us to study the effect of discontinued use (achieved by 21.0%). In multivariable linear regression models, snus use was associated with higher HDL cholesterol and triglyceride concentrations compared to non-tobacco use (p values ≤ 0.04), and it was associated with higher HDL cholesterol concentrations and lower triglyceride concentrations compared to cigarette smoking (p values ≤ 0.02). Snus use was not associated with non-HDL cholesterol concentrations, irrespective of the comparison group (p values ≥ 0.07). There was no indication that higher intensity of snus use led to a worse lipid profile, given that high-consumers had higher HDL cholesterol concentrations than low-consumers (p value = 0.02), or that discontinuation of snus use led to a better lipid profile, given that continued users had lower triglyceride concentrations than discontinued users (p value = 0.03). Further studies are needed to confirm or refute our findings.

Current tobacco use and SARS-CoV-2 infection in two Norwegian population-based cohorts.

BACKGROUND: Clear evidence of an increased risk for SARS-CoV-2 infection among smokers has not been established. We aimed to investigate associations between cigarette smoking or use of snus (snuff) and other nicotine-containing products and a positive SARS-CoV-2 test, taking test behavior into account. METHODS: Current tobacco use and testing behavior during the pandemic were recorded by adult participants from the Norwegian Mother, Father and Child Cohort Study and The Norwegian Influenza Pregnancy Cohort. SARS-CoV-2 infection status was obtained from The Norwegian Surveillance System for Communicable Diseases (MSIS) in May 2021 (n = 78,860) and antibody measurements (n = 5581). We used logistic regression models stratified by gender and adjusted for age, education, region, number of household members, and work situation. RESULTS: Snus use was more common among men (26%) than women (9%) and more prevalent than cigarette smoking. We found no clear associations between cigarette smoking or snus and a COVID-19 diagnosis among men. Associations among women were conflicting, indicating that cigarette smoke was negatively associated with a diagnosis (OR 0.51, 95% CI 0.35, 0.75), while no association was found for snus use (OR 1.07, 95% CI 0.86, 1.34). Compared with non-users of tobacco, both cigarette smokers and snus users had increased odds of being tested for SARS-CoV-2. CONCLUSIONS: Cigarette smoking, but not snus use, was negatively associated with SARS-CoV-2 infection in women. The lack of an association between snus use and SARS-CoV-2 infection in this population with prevalent snus use does not support the hypothesis of a protective effect of nicotine.

Polysubstance use and its correlation with psychosocial and health risk behaviours among more than 95,000 Norwegian adolescents during the COVID-19 pandemic (January to May 2021): a latent profile analysis.

Background: Polysubstance use represents an adolescent health risk; however, large-scale studies investigating this issue during the COVID-19 pandemic are scarce. We aim to (i) characterise substance use profiles among adolescents and (ii) identify correlates of such substance use profiles. Methods: Norwegian nationwide survey data from 2021 were analysed using latent profile analysis. Participants were 97,429 adolescents aged 13-18. We assessed cigarette, e-cigarette and snus use, alcohol consumption, and cannabis and other illicit drug use. Correlates included psychosocial variables, health risk behaviours, and COVID-19-related problems. Findings: We identified three adolescent profiles; those who use no substances (n = 88,890; 91%); those who use snus and alcohol (n = 6546; 7%); and those who use multiple substances (i.e., polysubstance profile; n = 1993; 2%). Boys, older adolescents, adolescents with lower socio-economic status, and those reporting low levels of parental control, and higher parental alcohol use, mental health problems, pain-related variables, and other health risk behaviours were most likely to be in the polysubstance profile. Adolescents with social and mental health issues related to COVID-19 were more at risk of being in the polysubstance profile. Adolescents who use snus and alcohol showed similar patterns of risk factors, but on a somewhat lower level than those in the polysubstance profile. Interpretation: Adolescents who use multiple substances have an unhealthier lifestyle, are at a higher risk of experiencing psychosocial impairments, and report more problems related to the COVID-19 pandemic. Preventative strategies to reduce polysubstance use might help promote psychosocial well-being in adolescents across various life domains. Funding: This study was funded by two grants from the Research Council of Norway (project #: 288083 and 300816). The Norwegian Directorate of Health has funded the data collection. The Research Council of Norway and the Norwegian Directorate of Health have not had any role in study design, data collection, data analysis, interpretation, and writing of the report.

Trends in Tobacco Use among 9th Graders in Sweden, 1991-2020.

Tobacco use was measured with self-reports of lifetime use of cigarettes and snus to examine trends in tobacco use among Swedish 9th graders over the period 1991-2020. Annual school surveys with nationally representative samples of 9th-grade students in Sweden covering the period 1991-2020 with a total sample of 163,617 students. We distinguished between the use of cigarettes only, use of snus only, dual use (use of both cigarettes and snus), and total tobacco use (use of any of these tobacco products). In addition to a graphical description of trends in the various measures of tobacco use, the correlation between these trends was calculated with the Pearson correlation coefficient (Rxy). The prevalence of total tobacco use declined from 72% in 1991 to 36% in 2020. The declining trend in total tobacco use was positively correlated with the trend in dual use (Rxy = 0.98) and the trend in cigarette use only (Rxy = 0.87). The trend in total tobacco use was, on the other hand, negatively correlated with snus use only (Rxy = -0.41), and snus use only was negatively correlated with cigarette use only (Rxy = -0.71). The situation became different after 2017 when total tobacco use increased as a result of an increasing prevalence of snus use. The sharp decline in tobacco use among 9th graders in Sweden over the past three decades is driven by declining cigarette use. The correlations between the various forms of tobacco use suggest that snus use may have contributed to the decline in cigarette use and, by that, overall tobacco use. The situation changed after 2017 when a sharp rise in snus use seems to have increased total tobacco use among adolescents in Sweden. A possible explanation behind this development is the introduction of a new form of snus called "All white snus", which was introduced in Sweden in 2014.

Harmful and potentially harmful constituents (HPHCs) in two novel nicotine pouch products in comparison with regular smokeless tobacco products and pharmaceutical nicotine replacement therapy products (NRTs).

BACKGROUND: Tobacco-free nicotine pouches is a novel category of oral nicotine-delivery products. Among current tobacco users such pouches may serve as a low-risk alternative to cigarettes or conventional, tobacco-based oral products e.g., snus and moist snuff. In the United States (U.S.), the market leading nicotine-pouch brand is ZYN®. However, no data on the chemical characteristics of ZYN have been published. METHODS: We screened for 43 compounds potentially present in tobacco products in seven oral nicotine-delivery products: ZYN (dry and moist), snus (General®), moist snuff (CRP2.1 and Grizzly Pouches Wintergreen), and two pharmaceutical, nicotine replacement therapy products (NRTs, Nicorette® lozenge and Nicotinell® gum). Thirty-six of the tested compounds are classified as harmful and potentially harmful constituents (HPHCs) by the Center for Tobacco Products at the U.S. Food and Drug Administration (FDA-CTP). Five additional compounds were included to cover the GOTHIATEK® product standard for Swedish snus and the last two compounds were chosen to include the four primary tobacco specific nitrosamines (TSNAs). RESULTS: The tested products contained nicotine at varying levels. The two ZYN products contained no nitrosamines or polycyclic aromatic hydrocarbons (PAHs) but low levels of ammonia, chromium, formaldehyde, and nickel. In the NRT products we quantified low levels of acetaldehyde, ammonia, cadmium, chromium, lead, nickel, uranium-235, and uranium-238. The largest number (27) and generally the highest levels of HPHCs were quantified in the moist snuff products. For example, they contained six out of seven tested PAHs, and seven out of ten nitrosamines (including NNN and NNK). A total of 19 compounds, none of which were PAHs, were quantified at low levels in the snus product. NNN and NNK levels were five to 12-fold lower in snus compared to the moist snuff products. CONCLUSIONS: No nitrosamines or PAHs were quantified in the ZYN and NRT products. Overall, the number of quantified HPHCs were similar between ZYN and NRT products and found at low levels.

Prevalence and persistence of Neisseria meningitidis carriage in Swedish university students.

The bacterium Neisseria meningitidis causes life-threatening disease worldwide, typically with a clinical presentation of sepsis or meningitis, but can be carried asymptomatically as part of the normal human oropharyngeal microbiota. The aim of this study was to examine N. meningitidis carriage with regard to prevalence, risk factors for carriage, distribution of meningococcal lineages and persistence of meningococcal carriage. Throat samples and data from a self-reported questionnaire were obtained from 2744 university students (median age: 23 years) at a university in Sweden on four occasions during a 12-month period. Meningococcal isolates were characterised using whole-genome sequencing. The carriage rate among the students was 9.1% (319/3488; 95% CI 8.2-10.1). Factors associated with higher carriage rate were age ≤22 years, previous tonsillectomy, cigarette smoking, drinking alcohol and attending parties, pubs and clubs. Female gender and sharing a household with children aged 0-9 years were associated with lower carriage. The most frequent genogroups were capsule null locus (cnl), group B and group Y and the most commonly identified clonal complexes (cc) were cc198 and cc23. Persistent carriage with the same meningococcal strain for 12 months was observed in two students. Follow-up times exceeding 12 months are recommended for future studies investigating long-term carriage of N. meningitidis.

Oral lesions associated with daily use of snus, a moist smokeless tobacco product. A cross-sectional study among Norwegian adolescents.

OBJECTIVE: Use of snus, a moist, smokeless tobacco product, may lead to local changes in the oral mucous membrane in the area where the snus is placed. It can also cause irreversible gingival retraction. This cross-sectional study aimed to investigate the relationship between use of snus, oral mucosal lesions (snus induced lesions) and gingival retractions among adolescents in Norway. MATERIAL AND METHODS: All 18-20 years olds visiting public dental health clinics in the south-eastern region of Norway between October 2015 and December 2016 were invited to participate. All participants (n = 1363) filled in an electronic questionnaire before a clinical examination. Of these, 216 used snus daily. RESULTS: Snus induced lesions were observed in 79.2% of daily snus using participants. In adjusted regression analyses, the odds of having a more severe lesion as opposed to a less severe lesion were 1.12 times greater for each additional box of snus used in a month (p < .01). Women were 46% less likely to have a severe lesion than men (p = .03). Gingival retractions were observed in 18.4% of the participants. The odds for dental retraction were significantly higher by 34% for each year of snus use. CONCLUSIONS: Most of the adolescents using snus had snus induced lesions, whereas approximately one-fifth had gingival retractions. The severity of the lesion and gingival retraction increased with the amount of snus boxes used and the duration of the snus use, respectively.