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.

Development and Evaluation of a Serious Game Application to Engage University Students in Critical Thinking About Health Claims: Mixed Methods Study.

BACKGROUND: Misleading health claims are widespread in the media, and making choices based on such claims can negatively affect health. Thus, developing effective learning resources to enable people to think critically about health claims is of great value. Serious games can become an effective learning resource in this respect, as they can affect motivation and learning. OBJECTIVE: This study aims to document how user insights and input can inform the concept and development of a serious game application in critical thinking about health claims in addition to gathering user experiences with the game application. METHODS: This was a mixed methods study in 4 successive phases with both qualitative and quantitative data collected in the period from 2020-2022. Qualitative data on design and development were obtained from 4 unrecorded discussions, and qualitative evaluation data were obtained from 1 recorded focus group interview and 3 open-ended questions in the game application. The quantitative data originate from user statistics. The qualitative data were analyzed thematically, and user data were analyzed using nonparametric tests. RESULTS: The first unrecorded discussion revealed that the students' (3 participants') assessment of whether a claim was reliable or not was limited to performing Google searches when faced with an ad for a health intervention. On the basis of the acquired knowledge of the target group, the game's prerequisites, and the technical possibilities, a pilot of the game was created and reviewed question by question in 3 unrecorded discussions (6 participants). After adjustments, the game was advertised at the Oslo Metropolitan University, and 193 students tested the game. A correlation (r=0.77; P<.001) was found between the number of replays and total points achieved in the game. There was no demonstrable difference (P=.07) between the total scores of students from different faculties. Overall, 36.3% (70/193) of the students answered the evaluation questions in the game. They used words such as "fun" and "educational" about the experiences with the game, and words such as "motivating" and "engaging" related to the learning experience. The design was described as "varied" and "user-friendly." Suggested improvements include adding references, more games and modules, more difficult questions, and an introductory text explaining the game. The results from the focus group interview (4 participants) corresponded to a large extent with the results of the open-ended questions in the game. CONCLUSIONS: We found that user insights and inputs can be successfully used in the concept and development of a serious game that aims to engage students to think critically about health claims. The mixed methods evaluation revealed that the users experienced the game as educational and fun. Future research may focus on assessing the effect of the serious game on learning outcomes and health choices in randomized trials.

Use of Swedish smokeless tobacco during pregnancy: A systematic review of pregnancy and early life health risk.

BACKGROUND AND AIMS: Smokeless tobacco is a heterogeneous product group with diverse composition and prevalence globally. Tobacco use during pregnancy is concerning due to the risk of adverse pregnancy outcomes and effects on child health. Nicotine may mediate several of these effects. This systematic review measured health outcomes from Swedish smokeless tobacco (snus) use during pregnancy. METHOD: Literature search was conducted by an information specialist in May 2022. We included human studies of snus use during pregnancy compared with no tobacco use, assessed risk of bias, conducted a meta-analysis and assessed confidence in effect-estimates using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: We included 18 cohort studies (42 to 1 006 398 participants). Snus use during pregnancy probably (moderate confidence in risk estimates) increase the risk of neonatal apnea, adjusted odds ratio 95% confidence interval [aOR (95% CI)] 1.96 (1.30 to 2.96). Snus use during pregnancy possibly (low confidence in risk estimates) increase the risk of stillbirths aOR 1.43 (1.02 to 1.99), extremely premature births aOR 1.69 (1.17 to 2.45), moderately premature birth aOR 1.26 (1.15 to 1.38), SGA aOR 1.26 (1.09 to 1.46), reduced birth weight mean difference of 72.47 g (110.58 g to 34.35 g reduction) and oral cleft malformations aOR 1.48 (1.00 to 2.21). It is uncertain (low confidence in risk estimates, CI crossing 1) whether snus use during pregnancy affects risk of preeclampsia aOR 1.11 (0.97 to 1.28), antenatal bleeding aOR 1.15 (0.92 to 1.44) and very premature birth aOR 1.26 (0.95 to 1.66). Risk of early neonatal mortality and altered heart rate variability is uncertain, very low confidence. Snus using mothers had increased prevalence of caesarean sections, low confidence. CONCLUSIONS: This systematic review reveals that use of smokeless tobacco (snus) during pregnancy may adversely impact the developing child.

Patient involvement in relative effectiveness assessments in the European Network for Health Technology Assessment.

Patient involvement in the process of producing health technology assessments has become increasingly important. In the European Network for Health Technology Assessment (EUnetHTA), several approaches to patient involvement were explored. The outcome was a document on "Patient Input in Relative Effectiveness Assessments" that is available for access and was published in 2019.The aim of this article is to analyze the experience gained by EUnetHTA in patient involvement for EUnetHTA assessment production, describe and quantify the approaches used, and outline the challenges and avenues for the improvement of current processes.Patients were involved in twenty-three of thirty-six pharmaceutical and other technology EUnetHTA assessments from June 2016 until the end of November 2019. Approaches to patient involvement included using a patient input template, one-on-one conversations, group conversations, scoping meeting with patients, and other approaches.Although it is recognized that patient involvement is important to understand the needs of the target patient population, challenges remain with timely patient involvement. Additionally, further efforts are needed to guide assessment teams on how to implement and enhance the visibility of patient input in assessments.

Are the health risks of moist oral snuff (snus) underestimated? / Er helserisikoen ved snus undervurdert?

The use of moist oral snuff (snus) has increased significantly, particularly among young adults who have not previously smoked. Snus increases the risk of cancer, cardiovascular disease, type-2 diabetes and birth defects.