Lee 2 reviewed 11 studies from Sweden and the USA in 2007 and found an association between smokeless tobacco use and increased heart disease risk based on eight studies, increased stroke risk based on five studies and increased overall circulatory disease risk based on three studies. Several reviews of smokeless tobacco use and circulatory disease risk have been conducted previously. Moreover, disease burden calculations for smokeless tobacco in the USA are generally unavailable for these conditions. 1 Although some types of smokeless tobacco have been found to be associated with circulatory conditions including heart disease and stroke, 2 3 comprehensive reviews of this association in high-income countries may be out of date or limited by the number of study estimates they identified. 1 In the USA, it has been estimated that smokeless tobacco use was responsible for approximately 1600 new cases of oral cancer, 500 new cases of pancreatic cancer and 200 new cases of oesophageal cancer in 2008. Globally, more than 300 million people use these products, many of them in low-income countries. The health effects of smokeless tobacco use are of considerable research and public health interest.
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