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Introduction
Prior to the 20th century, in the USA, tobacco was primarily consumed as leaves placed between the cheek and gums and occasionally chewed. 1 While cigarettes are now the most popular tobacco product, since the 1980s, moist snuff use has increased. 2-6 In 2009, approximately 3.5% of US adults used smokeless tobacco, and 75% of the smokeless tobacco market was moist snuff: cured tobacco ground into fine particles where a pinch or 'dip' is placed between the cheek and gum. 7 8 Traditional chewing tobacco requires users to expectorate, and it has been associated primarily with outdoor male activities.
Since 2006, two leading US cigarette companies, RJ Reynolds (parent company Reynolds American Inc.) and Philip Morris (parent company Altria), acquired smokeless tobacco companies and began to market new snus products. 9 Snus (rhymes with 'loose') is finely ground moist tobacco snuff packaged in small porous pouches that are placed between the cheek and gum and traditionally used in Scandinavia. The juices produced in the mouth when using snus are swallowed rather than spit out. In Sweden, snus processing typically involves heat treatment or pasteurisation, which is thought to reduce carcinogens, such as tobacco-specific nitrosamines, compared with traditional US chewing tobacco. 10 US snus marketing has emphasised the Swedish origins of snus ( figure 1 ). However, it is unknown whether products currently marketed with the name 'snus' in the USA are processed in the same way as Swedish snus, and limited studies of product composition suggest that the American and Swedish products are not equivalent. 11
Furthermore, snus products in the USA have been promoted as line extensions of powerful cigarette brands: Marlboro and Camel. Following test marketing, both Camel and Marlboro snus products were launched nationally in 2009 and 2010 respectively, 12 in cities that have smoke-free laws in workplaces, bars or restaurants. 13 With increasing clean indoor air laws, snus has been marketed as a product that could be used discreetly in public, unlike chewing tobacco (which requires spitting) 14 or cigarettes ( figure 2 ). 12 Snus products are suggested for use in bars, offices and airplanes 'when smoking isn't an option' ( figure 3 ). In this way, snus has been marketed primarily as an adjunct to smoking, rather than...