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The emergence of nicotine pouches\u2014commonly referred to as \u2018white snus\u2019 in Sweden\u2014that deliver comparable nicotine without tobacco constituents adds complexity to a heterogeneous landscape and raises questions about whether cardiovascular risk follows nicotine exposure regardless of product type. We explore epidemiological and mechanistic evidence on snus and cardiovascular disease, the contributions of nicotine versus tobacco\u2010specific nitrosamines (TSNAs) to risks, and identify knowledge gaps, with focus on novel nicotine products and the research opportunity offered by the Swedish Tobacco Cohort (SWETOC). Epidemiological evidence suggests elevated cardiovascular disease (CVD) mortality among snus users, with the most consistent signals for fatal myocardial infarction and heart failure. Associations with incident atherosclerotic events are more heterogeneous. Mechanistic evidence points to nicotine\u2010mediated pathways, including sympathetic activation, endothelial dysfunction and increased arterial stiffness, whereas evidence for TSNA\u2010driven CVD risk remains sparse, and declining TSNA levels in modern Swedish snus make that path less likely and harder to study. Nicotine pouches deliver comparable or higher systemic nicotine than conventional snus but lack long\u2010term cardiovascular outcome data. Real\u2010world cessation data from Denmark suggest structured programmes can achieve 6\u2010month abstinence rates of approximately 53% among non\u2010smoking nicotine users. The evidence supports nicotine as the primary driver of snus\u2010associated CVD risk, with important implications for the cardiovascular safety of novel nicotine products. Evidence is needed to inform public health guidance, clinical advice and regulatory decisions. SWETOC represents a unique infrastructure to generate this evidence.<\/jats:p>","DOI":"10.1111\/joim.70160","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T03:54:53Z","timestamp":1788839693000},"page":"541-552","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Snus, nicotine pouches and cardiovascular disease: Evidence, mechanisms, and the challenge of novel nicotine products"],"prefix":"10.1111","volume":"300","author":[{"given":"Magnus","family":"Olsson","sequence":"first","affiliation":[{"name":"Faculty of Odontology, Health Technology Assessment\u2010Odontology (HTA\u2010O) Malm\u00f6 University  Malm\u00f6 Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7161-3416","authenticated-orcid":false,"given":"Hanne","family":"T\u00f8nnesen","sequence":"additional","affiliation":[{"name":"WHO\u2010CC for Evidence\u2010Based Clinical Health Promotion, The Parker Institute, Bispebjerg\u2010Frederiksberg Hospital University of Copenhagen  Frederiksberg Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jakob","family":"Hedberg","sequence":"additional","affiliation":[{"name":"Department of Surgical Sciences Uppsala University  Uppsala Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2247-8454","authenticated-orcid":false,"given":"Johan","family":"Sundstr\u00f6m","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Clinical Epidemiology Uppsala University  Uppsala Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva","family":"Nordendahl","sequence":"additional","affiliation":[{"name":"Clinical Epidemiology Division, Department of Medicine Karolinska Institutet  Solna Sweden"},{"name":"Department of Periodontology Eastman Institute, Stockholm AB  Stockholm Sweden"},{"name":"Department of Dental Medicine Periodontology and Dental Prophylaxis Unit Karolinska Institutet  Huddinge Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2100-2446","authenticated-orcid":false,"given":"Bj\u00f6rn","family":"Klinge","sequence":"additional","affiliation":[{"name":"Department of Dental Medicine Periodontology and Dental Prophylaxis Unit Karolinska Institutet  Huddinge Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7269-6399","authenticated-orcid":false,"given":"Michael","family":"Fored","sequence":"additional","affiliation":[{"name":"Department of Periodontology Eastman Institute, Stockholm AB  Stockholm Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cecilia","family":"Magnusson","sequence":"additional","affiliation":[{"name":"Department of Global Public Health Karolinska Institutet  Solna Sweden"},{"name":"Centre for Epidemiology and Community Medicine Stockholm Health Care District  Stockholm Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8298-539X","authenticated-orcid":false,"given":"Daniel","family":"J\u00f6nsson","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences Malm\u00f6 Lund University  Malm\u00f6 Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7573-3220","authenticated-orcid":false,"given":"Peter","family":"Persson","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences Malm\u00f6 Lund University  Malm\u00f6 Sweden"},{"name":"Public Dental Service of Sk\u00e5ne  Lund Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5248-9202","authenticated-orcid":false,"given":"Aron","family":"Naimi\u2010Akbar","sequence":"additional","affiliation":[{"name":"Faculty of Odontology, Health Technology Assessment\u2010Odontology (HTA\u2010O) Malm\u00f6 University  Malm\u00f6 Sweden"},{"name":"Division of Oral Diagnostics and Surgery, Department of Dental Medicine Karolinska Institutet  Huddinge Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,7]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)00367-2"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2022.11.001"},{"key":"e_1_2_12_4_1","unstructured":"Public Health Agency of Sweden.Use of tobacco and nicotine products.Sweden:Public Health Agency; 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