Abstract
Introduction: Combustible tobacco smoking is strongly associated with the development of cardiovascular disease (CVD). However, evidence is limited as to whether smokeless tobacco (ST) use is associated with CVD. Methods: Using data from 4347 adults in the Population Assessment of Tobacco and Health Study (2013-2014), we compared geometric mean concentrations of CVD-related harm biomarkers and biomarkers of exposure among current exclusive ST product users and exclusive cigarette smokers—in relation to nicotine exposure—and never tobacco users, adjusting for age, sex, race/ethnicity, income, BMI and CVD. Biomarker levels among exclusive ST users who were former established cigarette smokers were examined and compared to levels among exclusive cigarette smokers. Results: Compared to cigarette smokers, ST users had significantly higher concentrations of total nicotine equivalents (TNE) but lower concentrations of inflammatory (high-sensitivity C-Reactive-Protein, interleukin-6, intercellular adhesion molecule, fibrinogen) and oxidative stress (8-isoprostane) biomarkers (all P<0.05). Biomarker levels among ST users were similar to never smokers. Exclusive ST users who were former cigarette smokers had lower levels of inflammatory and oxidative stress biomarkers and biomarkers of exposure (including cadmium, lead, 1-hydroxypyrene, acrylonitrile and acrolein), compared to cigarettes smokers (p<0.05), despite having higher TNE levels (P<0.05). In cigarette smokers, but not among ST users, inflammatory biomarkers and TNE were highly correlated. Conclusions: ST use is not associated with increases in biomarkers of CVD-related harm and exposure, compared to never smokers, despite exposure to nicotine at levels higher than those observed among cigarette smokers. These findings support the concept that increases in CVD risk among cigarette smokers is caused primarily by constituents of tobacco smoke other than nicotine.
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