Given this trajectory, the most appropriate messages for young males in rural areas may be those that are general messages that target all tobacco use rather than ST- or smoking-specific messages. This suggestion is consistent with a similar recommendation of Bombard, DZNeP CAS Rock, Pederson, and Asman (2008) based on population estimates using 2002 and 2004 National Youth Tobacco Survey data indicating that 62% of male middle school and high school cigarette smokers used other tobacco products, especially ST and cigars. A limitation of our study is that our self-reported findings are not validated by biochemical assay due to budgetary constraints. Research has indicated, however, that biochemical checks may be omitted without serious risk to reliability and validity under rigorous research conditions where confidentiality has been promised and accepted (Akers, Massey, Clarke, & Lauer, 1983).

The results of this study indicate that a high school-based nurse-led tobacco intervention program facilitates ST use cessation among nonsmoking high school males in rural areas. They also suggest that ST use in this young male population leads to smoking onset. Because of the high ST use among males in rural high schools and the potential reach of such a nurse-led program, the public health impact would be significant even with modest ST use cessation rates. Such programs are needed to help stop transition from experimental ST use to tobacco dependence and to counter the tobacco industry��s marketing of new moist snuff products with increased levels of free nicotine content (Alpert, Koh, & Connolly, 2008) designed to appeal to youth and new users (Carpenter, Connolly, Ayo-Yusef, & Ferris Wayne, 2009).

Policy makers need to (a) expand the role of high school nurses in rural areas to provide a youth tobacco intervention program such as the one reported here; (b) expand labels on ST products to include a warning that ST use has been shown to lead to smoking in groups of young male ST users; and (c) recommend funding of careful surveillance programs to determine whether or not the problem of ST use leading to later smoking among young males persists, especially in light of the tobacco industry��s aggressive marketing of new ST products. Funding This work was supported by the National Institute of Dental and Craniofacial Research at the National Institutes of Health (Grant Number US DHHS NIH/NIDCR P60 DE13058).

Declaration of Interests None declared. Acknowledgments We gratefully acknowledge the support of the school district superintendents in study Batimastat counties and the high school principals of the participating high schools in furthering our research. We also wish to acknowledge the invaluable efforts of the following county staff associated with either the County Office of Education or the County Department of Health Services: K. Kahuse, Modoc County; J. Welcome, Shasta County; B. Minert, Plumas County; W. Bushang, Lassen County; J.