Smokeless tobacco products sold in the United States include moist snuff (fermented moist ground tobacco leaves), dry snuff (heat dried and ground tobacco leaves) and chewing tobacco (cut tobacco leaves). As the most popular category, moist snuff accounts for 71% of the smokeless tobacco market in 2006.1 From 2000 to 2006, while cigarette sales declined by 13.8%,2 moist snuff sales volume increased 25.6% (from £64.8 million (in 2000) to £81.5 million (in 2006)),3 representing 1.1 billion tins. This increase raises questions of how manufacturers achieved such an increase in consumption.

Use of moist snuff can lead to oral cancer, gum disease, nicotine addiction and increased risk of cardiovascular disease, including heart attacks.4 5 Former cigarette smokers who switched to moist snuff after they stopped smoking also had higher risks of dying from smoking-related diseases—lung cancer, coronary heart disease, and stroke—than those who quit using tobacco entirely.6

Moist snuff is used as a small dip of tobacco placed between the cheek and gums, resulting in absorption of nicotine, the principal drug that causes dependence. The concentration of nicotine in moist snuff is one of the determinants of delivery to the bloodstream. The form of nicotine that is most easily absorbed in the mouth is called free, free-base or unionised nicotine.7^–10 Moist snuff contains the highest level of free nicotine among smokeless tobacco products in the United States. Specifically, according to 2003 data from the Massachusetts Department of Public Health (MDPH) nicotine disclosures database, the mean values for free nicotine were 3.52 mg/g, 0.71 mg/g and 0.11 mg/g tobacco for moist snuff, dry snuff and chewing tobacco, respectively.11 The estimated absorbed dose of nicotine from moist snuff (3.6 mg) is twice the amount from smoking (1.8 mg).12 Nicotine absorbed in the blood is rapidly distributed in the body, exposing the brain to high levels.11 Users of smokeless tobacco brands with higher levels of free nicotine have been found to exhibit greater dependence.13

Previous research suggests that since the 1970s, major manufacturers of smokeless tobacco products manipulated free nicotine to affect the speed and delivery of nicotine to the brain and to promote tolerance and addiction.7 9 10 14 15 Evidence from internal industry documents, the Food and Drug Administration (FDA) and other research suggest that control of free nicotine has been part of a graduation strategy that markets “starter” brands with relatively low free nicotine to young or other new users in order to minimise nausea, vomiting or dizziness.7 14 15 Then, according to the graduation strategy, brands with much higher levels of free nicotine are marketed to experienced users as nicotine dependence progresses.7 10 16

A primary means for modifying free nicotine content is altering the tobacco pH with additives such as sodium carbonate.9 10 15 17 18 The amount of nicotine in the unionised form is directly related to the pH of the nicotine-saliva solution19 and results in greater absorption and pharmacological response. The upper range of pH values seen in marketed products does not occur naturally in tobacco and therefore suggests manipulation.14

Manufacturers have also created a variety of brands and sub-brands which incorporate strategies such as sweet candy-like flavours, long tobacco leaf cuts in long strands and ready-to-use pouches, and can make nicotine dosing more attractive, easier and more uniform and appealing to new users, particularly youths.7 16 20 In contrast, fine tobacco leaf-cut products, which are in smaller particles, release nicotine rapidly because of their large surface area and deliver a sudden large dose of nicotine to the brain. This dosing could cause nausea, vomiting or dizziness in less experienced users.7 14 15 Fine-cut tobacco leaf products therefore are generally marketed towards more experienced dependent users.7 10 16

Findings to date regarding nicotine manipulation are based on publicly disclosed industry documents, public statements by manufacturers and empirical analyses of selected brands.7^–1021 22 We examined the possibility that company and brand-specific strategies of the major moist snuff manufacturers are controlling free nicotine content and ease of dosing with products that are designed and targeted to specific groups. To investigate this possibility, this study examines the current total US moist snuff market and quantitatively investigates whether: (1) levels of free nicotine of moist snuff products have increased over time; (2) the number and variety of sub-brands have increased over time; (3) changes in design, as reflected by variation in free nicotine associated with pH, tobacco leaf, or both, have enhanced the ease and uniformity of dosing; (4) marketing through price and advertising has increased; and (5) youth use has increased. For the purposes of this study, we do not examine a newly introduced form of moist snuff called “snus” with lower moisture content, which is targeted at smokers.

METHODS

We examined and analysed data from the following sources: (1) free nicotine levels from the MDPH nicotine disclosures database (2000–2006); (2) moist snuff use from the US Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health (NSDUH) (2002–2006)23; (3) sales and price data derived from ScanTrak scanner data licensed from ACNielsen (2003–2006)24; and (4) magazine advertising expenditures data licensed from TNS Media Intelligence.25

Free nicotine

In 1996, Massachusetts enacted a tobacco product disclosure law whereby the MDPH promulgated regulations requiring cigarette and smokeless tobacco manufacturers to file annual reports on nicotine yield for average consumers by brand.26 The requirements for smokeless tobacco reporting were based on federal rules that were published by the Centers for Disease Control and Prevention (CDC), adopted in 1996, and revised in 1999. While data reported by tobacco companies to the CDC remain confidential, the identical nicotine disclosure reports filed with MDPH are publicly available and represent brands sold nationally. The present analysis examines annual data for the years 2000–2006, corresponding to the years during which the revised CDC sampling guidelines have been in effect.

Companies are required to file an annual report to MDPH on 15 December of each year, listing for each sub-brand: (a) total nicotine content (mg/g dry weight of tobacco), (b) product moisture percentage, (c) tobacco pH and (d) free nicotine content (mg/g tobacco) (calculated by manufacturers based on reported pH and total nicotine content using the Henderson-Hasselbach (HH) equation). The laboratory methods used to measure these parameters are described in the Federal Register.27

We coded each moist snuff product for each of the four major manufacturers—Conwood, Swedish Match North America (SMNA), Swisher International (Swisher) and US Smokeless Tobacco (USSTC)—by brand (for example, Skoal), sub-brand (for example, Skoal Cherry Long Cut). We also coded by tobacco leaf-cut (fine-cut, long-cut, pouch), and flavouring category ascertained from the labels provided by the manufacturers (“Regular”, “Wintergreen” (analogous to menthol as a flavouring in cigarettes), or “Flavoured” (products with “candy” or other exotic flavours such as apple, cherry and peach)).

We computed mean free nicotine content (mg/g tobacco), pH, and total nicotine content (mg/g tobacco) for each category of brand, sub-brand, tobacco leaf-cut and flavour for each year. Temporal trends in the free nicotine content of moist snuff products were examined using regression analysis, with free nicotine content as the dependent variable and time (reporting year) as the independent variable. A multilevel mixed fixed-effects and random-effects regression model with a random intercept was used to account for the nested structure of sub-brands grouped within brand families, which were in turn grouped within manufacturers.28 29 Time was treated as the fixed effect in these models. A stepwise selection approach was used to determine which fixed effects (moisture, tobacco leaf-cut and/or flavouring category) to include in the regression model. The same modelling approach was used to examine temporal trends in total nicotine content and in pH.

Trends in consumption

We calculated moist snuff tobacco use (2002–2006) using data of the NSDUH. We exclude data before 2002 because survey design changes occurring in that year may have affected subsequent comparability. Current use of moist snuff (including individual moist snuff brands), and chewing tobacco were calculated using the survey variables SNFMON (use of snuff in the past month), CHWMON (use of chewing tobacco in the past month), SNF30BR2 (snuff brand used most often in the past month) and CHW30BR2 (chewing tobacco brand used most often in the past month) for each year by age (12–17 years vs 18–25 years vs 26 years and over) as well as by gender and race. Temporal trends in use were tested using regression analyses, and all analyses were conducted accounting for the complex survey sampling design and weighting.

Price and market share

Price and sales data (2003–2006) derived from ScanTrak scanner data licensed from ACNielsen were collected in US food stores with at least $2 million in annual sales, US drug stores with at least $1 million in annual sales and all US mass merchandisers, with the exception of Walmart. These samples represent approximately 95% of food and drug stores and 40% of mass merchandisers. We calculated average price per tin per brand per year (dividing the total dollar sales by the number of tins sold in the respective year) as well as market share per brand per year (dividing the total dollar sales of the brand by the total dollar sales of moist snuff products in the respective year).

Magazine advertising expenditures

Estimated quarterly magazine advertising expenditures for moist snuff products in magazines with national distribution (2006) were obtained in custom reports from Taylor Nelson Sofres Media Intelligence (TNS), a commercial vendor of advertising data that routinely monitors major consumer magazine titles and newspapers distributed in the United States. Total annual magazine advertising expenditures were computed by summing the expenditures for each advertisement over all four quarters for each brand family.

Data analyses were conducted using Stata version 10.0.30

RESULTS

Variation in free nicotine content of moist snuff products

Over the study period, free nicotine levels found in the moist snuff products of major manufacturers varied widely by brand and by tobacco leaf-cut. Each major manufacturer marketed brands during the study period, which covered a range of free nicotine levels, from 0.02 mg/g to 8.00 mg/g tobacco.

As an example, in 2006 Hawken long-cut by Conwood, previously identified as a “starter” brand,7 was the company’s only low free nicotine product with a level of 0.02 mg/g tobacco. However, free nicotine levels in their Kodiak (6.39 mg/g tobacco) and Grizzly (6.01 mg/g tobacco) fine-cut brands were much higher. A range was also found for SMNA, whose lowest free nicotine product was Renegades pouch with 2.86 mg/g tobacco, in contrast to its Longhorn fine cut brand which had 5.43 mg/g tobacco. Swisher’s lowest free nicotine product was Gold River with 0.06 mg/g tobacco, while its finest quality fine-cut brand had 6.38 mg/g tobacco (2003). USSTC has consistently marketed Skoal Bandits pouch products with lower free nicotine (2.08 mg/g tobacco) while Copenhagen (3.58 mg/g tobacco) and Husky (4.24 mg/g tobacco) fine-cut brands have had higher free nicotine.

Temporal trends in the free nicotine content by moist snuff manufacturer

Free nicotine content, controlling for tobacco leaf-cut, increased overall for two major manufacturers—Conwood (β_time = 0.237, p<0.001) and SMNA (β_time = 0.162, p = 0.008) (fig 1) while they decreased overall in USSTC brands (β_time = −0.120, p = 0.001) (fig 1) and showed no statistically significant temporal trend overall for Swisher brands (p = 0.552). The overall mean free nicotine content across major manufacturers’ brands were similar in year 2000. Mean (95% CI) were Conwood (4.11 (1.64) mg/g tobacco), SMNA (3.90 (1.46) mg/g tobacco), Swisher (3.39 (0.81) mg/g tobacco) and USSTC (4.42 (0.82) mg/g tobacco). By 2006, the mean free nicotine content of Conwood (5.39 (1.28) mg/g tobacco) and SMNA (5.11 (0.74) mg/g tobacco) brands were higher in comparison to that of Swisher (2.29 (0.72) mg/g tobacco), and USSTC (2.79 (0.35) mg/g) brands (fig 1).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1 Trend in free nicotine content by moist snuff manufacturer. SMNA, Swedish Match North America; UST, US Smokeless Tobacco.

Increases in free nicotine content were observed, for example, in Conwood’s Kodiak (β_time = 0.283, p = 0.001) and SMNA’s Timber Wolf (β_time = 0.221, p = 0.001) brands. Free nicotine content decreased in USSTC’s Skoal (β_time = −0.238, p<0.001), Revel (β_time = −0.501, p<0.001) and Rooster (β_time = −0.184, p = 0.048) brands and showed no temporal trend in Copenhagen (p = 0.352), Husky (p = 0.772) or Skoal Bandits (p = 0.241) brands.

Temporal trends in pH and nicotine content of moist snuff products

Temporal trends in pH generally paralleled the temporal trends in free nicotine content. For Conwood (β_time = 0.032, p = 0.001) and SMNA (β_time = 0.044, p<0.001) moist snuff products exhibited overall increasing pH, while for USSTC (β_time = −0.029, p<0.001) and Swisher (β_time = −0.034, p = 0.028) they exhibited overall decreasing pH. Parallel temporal trends between free nicotine content and pH were also evident at the brand level. For example, pH increased in Conwood’s Kodiak brand (β_time = 0.032, p<0.001) and SMNA’s Timber Wolf brand (β_time = 0.033, p<0.001), while it decreased in USSTC’s Skoal (β_time = −0.043, p<0.001) brand, corresponding to the observed changes in free nicotine content of these brands.

Mean total nicotine content controlling for tobacco leaf-cut increased overall during this period (β_time = 0.052, p = 0.044) but temporal trends in total nicotine content did not parallel the observed temporal trends in free nicotine content as was seen with pH. Total nicotine content was observed increasing only in Swisher’s (β_time = 0.234, p<0.001) brands and showed no temporal trend in Conwood’s (p = 0.465), SMNA’s (p = 0.142) or USSTC’s (p = 0.233) moist snuff products.

Trends in numbers of moist snuff brands and sub-brands

While the numbers of brands marketed by each manufacturer remained relatively constant over the study period, the numbers of sub-brand varieties increased dramatically, primarily among brands of USSTC and SMNA, and among long-cut, pouch, and flavoured brands in general (fig 2A–C). For example, USSTC increased the number of sub-brands marketed by 140% from 20 (2000) to 48 (2006), particularly long-cut, pouch and flavoured varieties. SMNA increased the number of sub-brands by 250% from six (2000) to a peak of 21 (2004) particularly long cut varieties, before decreasing it to 19 (2006) sub-brands. Conwood meanwhile increased the number of sub-brands only slightly, by two. The numbers of fine-cut and non-flavoured sub-brands also stayed relatively constant overall.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2 (A) Number of moist snuff tobacco product sub-brands per company. (B) Number of moist snuff tobacco product sub-brands per tobacco leaf-cut. (C) Number of moist snuff tobacco product sub-brands per flavour category. SMNA, Swedish Match North America; USSTC, US Smokeless Tobacco.

Temporal trends in the free nicotine content per tobacco leaf-cut

Mean free nicotine content (95% CI) (2000–2006) shown in figure 3 for each tobacco leaf-cut were highest in fine-cut products (4.65 (0.52) to 5.40 (0.70)); lower in long cut products (3.44 (0.49) to 4.10 (0.55)) and lowest in pouch products (0.86 (0.55) to 3.02 (0.89)). These differences in free nicotine content across tobacco leaf-cuts, controlling for year of sample, were statistically significant (p<0.05). Temporal trends in free nicotine content were not statistically significant among fine-cut (p = 0.674) or long-cut (p = 0.094) products, but did increase at a rate of 16% per year (p = 0.048) among pouch products.

• Download figure
• Open in new tab
• Download powerpoint

Figure 3 Mean free nicotine (mg/g tobacco) and 95% confidence intervals per tobacco leaf-cut 2000–2006.

Trends in moist snuff brand tobacco use by age, gender and race

Current moist snuff use among youths aged 12–17 years increased at an average of 6% per year, 2002–2006 (p = 0.012), particularly among white males (OR = 1.07, p = 0.010). Increases in current moist snuff use approaching statistical significance were observed for those of black race (OR = 1.48, p = 0.066) youths aged 12–17 years and people aged 18–25 years (OR = 1.03, p = 0.060). Statistically significant increases in moist snuff use were not observed among young females (p = 0.111) or among people aged 26 years and over (p = 0.651).

Moist snuff brands preferred by current youth moist snuff users aged 12–17 years in 2000 and 2006 are shown in table 1. Youth brands preferences (2006) differed with statistical significance from those of current moist snuff users aged 18 years and older (Pearson χ² = 2.229, p = 0.028). Youth preference for Grizzly brand has increased dramatically from 2002, when less than 1% of users identified it as their current brand, to 27% in 2006, making it the second most preferred brand (table 1). ACNielsen ScanTrak data also reflect a steep increase from 3% to 11% occurring since 2003 in Grizzly brand market share. At the same time, youth preference decreased by 6% for Copenhagen and by 9% for Skoal, the two historical leading brands among youths (table 1).

Length of time using starter and maintenance moist snuff brands by young people

Regression analysis, controlling for age of user, indicated that current users aged 12–21 years of more addictive, maintenance moist snuff brands with higher free nicotine such as Cougar, Timber Wolf, Husky, Longhorn and Grizzly, had used smokeless tobacco for more years than current users of lower free nicotine, “starter”, brands such as Hawken and Skoal (β_time = 0.488, p = 0.047). Except for Kodiak and Copenhagen, the individual brands used more often by more experienced users had higher free nicotine content and were priced lower than low free nicotine content “starter” brands (table 1).

Market share, average price and magazine advertising expenditures for moist snuff

Market share of moist snuff brands in 2006 and changes in market share since 2003 are shown in table 1. Increased market share was seen in Grizzly long-cut and fine-cut, Longhorn long-cut and fine-cut, Skoal pouches, and Husky fine-cut. Each of these products with the exception of Skoal pouches had high levels of free nicotine. The average price per tin (2006) of these moist snuff brands was low ($2.00 or less), in contrast to the average price per tin (2006) of brands with low free nicotine content such as Hawken, Renegades, Gold River and Skoal ($3.01 to $4.39) (table 1). Virtually all moist snuff magazine advertising expenditures in 2006 were for Skoal ($8.9 million), Copenhagen ($8.2 million), Timber Wolf ($1.3 million), Grizzly ($1.1 million) and Kodiak ($0.7 million) brands.

DISCUSSION

While cigarette sales have fallen recently, sales of moist snuff have risen 20% over the past 10 years and per-capita consumption has increased by 15% over the past six years.31 In particular, use among male adolescents has risen by 25% in the past five years. Our study finds that the manufacturers may have controlled free nicotine levels in combination with pricing and dosing through strategies involving widening the variety of sub-brands to feature an array of tobacco leaf-cuts and flavouring categories to attract young and/or inexperienced users in addition to more experienced long-term users.

Free nicotine concentrations of the snuff moist products of two of the major manufacturers, Conwood and SMNA, increased overall, notwithstanding some year-to-year fluctuation. These observed trends in free nicotine correspond closely to the shifts in market share of the major manufacturers, a finding that is consistent with previous research (Connolly GN. In the search for a perfect starter product: manipulation of nicotine in oral snuff brands. Unpublished, 1994). During this period, market share for Conwood and SMNA increased (from 14% to 26% and from 6% to 10%, respectively), while that of USSTC decreased (from 75% to 62%).1 Not surprisingly, RJ Reynolds Tobacco Company (RJRT), the country’s second largest cigarette manufacturer, acquired Conwood for $4.5 billion in 2006.

High free nicotine content was observed in particular among conventional brands including Kodiak, Grizzly, Longhorn, Timber Wolf, Husky and Copenhagen, which are popular among established, addicted users. These trends are consistent with targeting of the established, addicted user with products delivering nicotine in the more readily absorbable fine tobacco leaf-cut and with high pH. These people may be the subject of marketing strategies ostensibly promoting “consumer” or “brand loyalty” in order to maintain and increase market share.32^–34

Manufacturers appear to be controlling pH to manipulate free nicotine, rather than as a result of random variation of tobacco leaf, supporting past research identifying the graduation strategy. Observed changes in pH at the manufacturer and brand levels, parallel the observed changes in free nicotine. As found earlier, the highest pH levels found in the present study do not occur in aqueous extracts of natural tobacco whose levels have been reported to be typically in the range of 5.5–6.5.14 35

Limited studies show reductions in total tobacco specific nitrosamines (TSNA) in some of USSTC products, which do not explain the observed free nicotine trends. TSNA levels decreased in Skoal long-cut (measured as 64.0 μg/g tobacco in 200036 and 9.2 μg/g tobacco in 200637) and Copenhagen (measured as 41.1 μg/g tobacco in 200036 and 4.8 μg/g tobacco in 200637), whereas free nicotine levels decreased in only one (Skoal) of these two products.

Manufacturers, in particular USSTC and SMNA, increased the number of sub-brands marketed by 80% during the study period, apparently to increase their customer base and sales. Most new product introductions during this period had lower free nicotine content and were either long-cut, pouch and/or flavoured varieties aimed at making nicotine dosing attractive, and a more uniform and graduating dose for young and other new or inexperienced users. Product innovation can be a strong driver of use and is a strategy embraced by tobacco companies as reflected in USSTC’s 2006 Annual Report to Shareholders, “…we are committed to maintaining our relentless pursuit of breakthrough innovation, which already has led to our current test marketing of Skoal Dry and Revel”.32 The report highlights the introduction in 2007 of a new Skoal Citrus Blend product in long-cut and pouch forms and “twenty other potential new products in the pipeline.”32 Net can sales of new products launched within the last three years actually represented 11.7% of the company’s total moist smokeless tobacco net unit volume for 2006.32

While free nicotine content was increasing from 2000 to 2006 in the regular and traditional wintergreen products of Conwood and SMNA, it was decreasing in the flavoured products of USSTC. Decreasing free nicotine levels in USSTC products suggests that USSTC, whose heavily advertised Copenhagen and Skoal brands have historically dominated the younger market, may be targeting young people with low free nicotine moist snuff products, such as Skoal and Skoal Bandits, particularly the flavoured varieties, in order to achieve better long-term financial health. However, Conwood’s Grizzly with higher nicotine content has also gained popularity with youths, while relative youth use of Copenhagen and Skoal decreased. The increasing prevalence of Grizzly brand among youths may be due to low price, advertising and added flavourings and attests to how quickly young people can become dependent on higher nicotine products.

Starter brands with low pH and low free nicotine may be marketed as a way to encourage trial, with the intent of graduating new users up to higher nicotine brands with increased “kick” and promote long-term dependence.7 14 15 A major concern is that use of these products might serve as the initial pathway to nicotine addiction eventually leading to cigarette smoking.38 39 Studies have found that new smokeless users may be more likely to graduate to a higher nicotine delivery product including cigarettes than to switch down to a lower nicotine delivery product.13 40

While increases in market share occurred almost exclusively for moist snuff brands with high free nicotine levels and low price, the overall increase in moist snuff sales could have occurred for additional reasons. Before the introduction of starter brands in the 1970s smokeless tobacco use by young people was negligible.7 However, use of smokeless tobacco by adolescent boys rose dramatically between 1970 and 1991 and subsequently declined following sharp state tax increases and public education programmes.41 42 More recently, however, state and national tobacco education media campaigns have focused primarily on the harm of cigarette use, possibly leaving smokeless tobacco products viewed as a preferable alternative by youth. Meanwhile, the federal tax per tin remains one tenth of the tax per pack of cigarettes.43

Increased sales may also be resulting from smokers taking up moist snuff as a temporary substitute in settings where smoking is prohibited. Skoal Dry, designed to be spit-free, has been developed by USSTC specifically for smokers.32 Philip Morris (PM) has recently introduced its own version of moist snuff called “Marlboro Snuff” with lessened free nicotine as PM and other cigarette manufacturers are responding by pursing an “adjacency” strategy of selling smokeless tobacco, small cigars and other tobacco products in addition to cigarettes. RJRT has followed with the marketing of Camel Snus.

This study does not take into account potential differences in the amount of moist snuff used (and therefore nicotine consumed) by consumers in terms of frequency of dipping and length of time the product is kept in the mouth. The size of a “dip”, the usual dose taken of loose moist snuff products, is approximately 1.97 g tobacco and more variable because of the manner in which it is used than a portion packed pouch, which contains approximately 0.5 g tobacco per packet.17 44 Aside from the new snus products, brand-to-brand variation in pouch size is believed to be small, and since users can nevertheless adjust the amount of tobacco consumed with either form of moist snuff, these are expected to have little effect on the study results.

We note that ACNielsen ScanTrak market share and price data examined in the study do not include sales in convenience stores, comprising approximately 20% of market, or sales in Walmart stores, comprising approximately 50% of sales by mass merchandisers. Although the estimates may not precisely reflect the US moist snuff market, they are comparable to figures cited in the business literature and should be reasonably representative of the market.1

Legislation is pending in the US Senate that would require the FDA to regulate tobacco products as drug delivery devices for the pharmaceutical agent, nicotine. If the legislation is passed, the FDA should consider limits on free nicotine and control by pH in order to prevent companies from manipulating free nicotine to induce addiction among young people or from increasing free nicotine to enhance dependence among more experienced users. Federal taxes should be equalised between cigarettes and other tobacco products. Of note, manufacturers should adopt the Swedish Gothiatek standard for all moist snuff brands, designed, but not proved, to “continuously reduce or eliminate alleged harmful components in tobacco”.37 45 Full content disclosure as well as tobacco type and leaf-cut should be required for all marketed brands and printed on the package, including total and free nicotine, pH, TSNAs, flavourings and all other additives to enable close and continued monitoring of changes in product design that could affect populations at high risk.

A combination of factors such as brand proliferation, control of free nicotine, product design features that enhance or ease the delivery of nicotine, price discounts and clean indoor air policies most likely resulted in the expanded consumption of moist snuff, particularly among young people. Of all of these factors, nicotine must be considered one of the most potent, as is underscored by Conwood’s growth.