title: Smokeless tobacco products sold in Massachusetts from 2003 to 2012: trends and variations in brand availability, nicotine contents and design features.
abstract: BACKGROUND
  Sales of smokeless tobacco products have increased in the USA. More than one in eight males in the 12th grade are current users of smokeless tobacco. Surveillance data examining nicotine levels of smokeless tobacco subsequent to 2006 have not been reported in the literature.
  
  
  METHODS
  Data on nicotine levels and design features (eg, pH, moisture content, leaf cut and flavour) of smokeless tobacco products sold in Massachusetts were obtained from manufacturers between 2003 and 2012. Design features, levels and temporal trends in unionised (free) nicotine and nicotine content of smokeless tobacco products were analysed overall and by manufacturer and product type.
  
  
  RESULTS
  The annual total number of moist snuff products increased from 99 in 2003 to 127 in 2012. The annual total number of reported snus products increased from 4 in 2003 to the highest level of 62 in 2011, before decreasing to 26 in 2012. Overall, mean unionised (free) nicotine remained relatively stable (β=0.018 (95% CI -0.014 to 0.050) mg/g dry weight/year) from 2003 to 2012. However, both levels and temporal trends of mean free nicotine varied significantly among manufacturers (p<0.001). Since 2003, the free nicotine content of snus has increased at an overall rate of 0.192 (95% CI 0.138 to 0.246) mg/g dry weight/year, but varied by manufacturer (p<0.001).
  
  
  CONCLUSIONS
  The number of smokeless tobacco products increased in the Massachusetts market. Further, mean unionised (free) nicotine levels in smokeless tobacco products of several manufacturers continued to rise despite decreasing levels from other manufacturers. The current success in tobacco control is very likely undermined without government surveillance, regulation and widespread public disclosure of nicotine levels in these products.
authors.affiliation: Bureau of Community Health and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA.
authors.forename: Doris
authors.initials: D
authors.lastname: Cullen
authors.affiliation: Bureau of Community Health and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA.
authors.forename: Lois
authors.initials: L
authors.lastname: Keithly
authors.affiliation: Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kane
authors.affiliation: Bureau of Community Health and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Land
authors.affiliation: Bureau of Community Health and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Paskowsky
authors.affiliation: Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
authors.forename: Lili
authors.initials: L
authors.lastname: Chen
authors.affiliation: Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
authors.forename: Rashelle
authors.initials: R
authors.lastname: Hayes
authors.affiliation: Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
authors.forename: Wenjun
authors.initials: W
authors.lastname: Li
mesh_terms: D003132:Commerce / Q000706:statistics & numerical data*; D006863:Hydrogen-Ion Concentration; D008404:Massachusetts; D009538:Nicotine / Q000032:analysis*; D013649:Taste; D014030:Tobacco, Smokeless / Q000145:classification / Q000191:economics / Q000706:statistics & numerical data / Q000600:supply & distribution; D014867:Water / Q000032:analysis
chemical_list: D014867:Water; D009538:Nicotine
keywords: Nicotine; Non-cigarette tobacco products; Public policy; Surveillance and monitoring