Article Text


Original research article
Smokeless tobacco use and circulatory disease risk: a systematic review and meta-analysis
  1. Brian L Rostron,
  2. Joanne T Chang,
  3. Gabriella M Anic,
  4. Manju Tanwar,
  5. Cindy M Chang and
  6. Catherine G Corey
  1. Center for Tobacco Products, Food and Drug Administration, Silver Spring, Maryland, USA
  1. Correspondence to Dr Brian L Rostron; brian.rostron{at}


Objective Smokeless tobacco use is a public health issue throughout the world, but reviews and analyses of circulatory disease risks associated with smokeless tobacco use may be outdated or incomplete. This study provides a thorough and comprehensive review and meta-analysis of circulatory disease risks in high-income countries, including recently published study estimates.

Methods We conducted a systematic review of studies of circulatory disease risks associated with smokeless tobacco use in Europe and North America that were identified from electronic databases and reference lists. Study estimates were extracted by region, smokeless tobacco use status, cigarette smoking status, and circulatory condition and combined in meta-analysis using a random-effects model. We used the Newcastle-Ottawa scale to assess study quality and risk of bias.

Results We identified 17 relevant cohort studies, two pooled analyses, five case–control studies and one cross-sectional analysis. We found increased risk of heart disease (relative risk (RR) 1.17, 95% CI 1.09 to 1.27) and stroke (RR 1.28, 95% CI 1.01 to 1.62) among US smokeless tobacco users compared with non-users. Increased circulatory disease risk was not observed among Swedish smokeless tobacco users.

Conclusion US smokeless tobacco users were found to have increased risk of heart disease and stroke.

  • cardiovascular disease
  • heart disease
  • stroke
  • smokeless tobacco

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Correction notice This article has been corrected since it published Online First. There were some instances of redundant texts (instructions from the authors) which have been removed now.

  • Contributors BLR and CGC designed the review and developed the study protocol. MT designed the search strategy, and JTC and GMA conducted the literature review. BLR conducted the analysis and wrote the draft manuscript. All of the coauthors reviewed the manuscript and provided critical input.

  • Funding Funding for this project was provided by the Center for Tobacco Products, US Food and Drug Administration.

  • Disclaimer This publication represents the views of the authors and does not represent FDA/CTP position or policy.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no additional data available.

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