List of Ingredients Added in the Manufacture of Smokeless Tobacco Products

Form Approved

OMB No. 0920-0338

Exp. 04/31/2011

Recommended Format for Smokeless Tobacco Nicotine Data Reporting - CSTHEA

Please attach additional pages if necessary

Date

Office on Smoking and Health

Attn. FCLAA Program Manager

4770 Buford Hwy., NE, MS K-50

Atlanta, GA 30341

This nicotine report is being submitted pursuant to the Comprehensive Smokeless Tobacco Health Education Act (CSTHEA), 15 U.S.C. §4403(a).

Manufacturer* (Please indicate if the product is manufactured for another company)

Variety (Including brand families and brand variations)

Brand Name (e.g., Skoal Bandits, Skoal Long Cut Cherry, Skoal Long Cut Wintergreen, etc.)

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a cigarette manufacturer, packager, or importer, the form must specify on whose behalf the submission is being made.

Product category (check one)

______Dry snuff

______Moist (wet) snuff

______Snuff portion pouch

______Snus

______Snus portion pouch

______Plug

______Twist

______Loose leaf

______Compressed (pellet, tablet)

______Other (specify)

Documentation of method used for random sample section

Documentation of Standards Addition Assay, including nicotine concentrations selected for standard curve

Smokeless Tobacco Analytical Data
	Sample Date	Manufacture Date	Lot Number	Sample Fraction1	Age of the product in days when received by testing facility/storage conditions prior to analysis	Nicotine2	Total Moisture3	pH	Estimated unionized (free) nicotine2	Estimated unionized (free) nicotine3
1
2
3
4
					Final mean value with 95% confidence interval
					Range of values
					Estimated precision of the mean4

¹Number of randomly sampled, sealed, packaged (so as to be representative of the product that is sold to the public) smokeless tobacco products selected per sampling date; ²Units for nicotine and estimated unionized (free) nicotine content are milligrams of nicotine (or unionized (free) nicotine) per gram of tobacco (mg/g); ³Total moisture and estimated unionized (free) nicotine as a percentage (%); ⁴Reported as the standard deviation.

Public reporting burden of this collection of information is estimated to average 6.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338).