• Ann Post, Hans Gilljam, Ingvar Rosendahl, Sven Bremberg, and Maria Rosaria Galanti.
• Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden. ann.post@ki.se
• Addiction. 2010 Apr 1; 105 (4): 740-6.

AimsTo determine whether symptoms of nicotine dependence, addiction and withdrawal symptoms differ between exclusive smokers, exclusive snus (moist snuff) users and dual users.DesignA cross-sectional survey of a cohort subsample. Setting County of Stockholm, Sweden.ParticipantsCurrent exclusive smokers (n = 466), exclusive snus users (n = 209) and dual users (n = 144), mean age 17.6 years.MeasurementsSelf-reported life-time experience of nicotine dependence and withdrawal symptoms in periods of discontinued tobacco use. Selected items from the modified Fagerstöm Tolerance Questionnaire (mFTQ), the Hooked on Nicotine Checklist (HONC) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).FindingsThe odds ratio of endorsing each of four mFTQ items as well as the HONC item investigating the risk of feeling addicted to tobacco was two to five-fold higher for exclusive snus users and for dual users compared to exclusive smokers. One DSM-IV item (difficult to refrain from use) was elevated among dual users compared to smokers. Dual users reported the highest prevalence of any withdrawal symptom in contrast to exclusive snus users, who reported a lower risk of withdrawal symptoms compared to exclusive smokers.ConclusionsSmokeless tobacco users show symptoms of nicotine dependence at least as frequently as cigarette smokers. Symptoms of nicotine dependence and of withdrawal during quit attempts are particularly frequent in the subgroup of users who combine smokeless tobacco with smoking.

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