Use of smokeless tobacco in the United States has been relatively constant in recent years, as tobacco companies continue aggressive marketing campaigns. The health effects of smokeless tobacco use need further documentation. Thus, the authors examined whether current use of smokeless tobacco was associated with increased incidence of cardiovascular disease (CVD) in 14,498 men and women aged 45-64 years at baseline (1987-1989) in the Atherosclerosis Risk in Communities (ARIC) Study. There were 2,572 incident CVD events (myocardial infarction, coronary revascularization, coronary death, or stroke) during a median of 16.7 years of follow-up (maximum = 19.1 years). Current use of smokeless tobacco at baseline was associated with 1.27-fold greater CVD incidence (95% confidence interval: 1.06, 1.52) than was nonuse, independently of demographic, socioeconomic, and lifestyle and other tobacco-related variables. Past use of smokeless tobacco was not associated with CVD incidence. In conclusion, current use of smokeless tobacco was associated with increased risk of CVD incidence in ARIC cigarette nonsmokers. Current users of smokeless tobacco should be informed of its harm and advised to quit the practice. Current cigarette smokers should also be given sufficient information on safe, therapeutic methods of quitting which do not include switching to smokeless tobacco.