Cochrane for Clinicians

Putting Evidence into Practice

Interventions to Help Patients Reduce or Eliminate the Use of Smokeless Tobacco


Am Fam Physician. 2009 Dec 1;80(11):1226-1227.

Clinical Scenario

A 45-year-old man asks for help with stopping his use of chewing tobacco.

Clinical Question

What clinical interventions can help patients reduce or eliminate their use of smokeless tobacco products?

Evidence-Based Answer

Although the studies of behavior interventions were heterogeneous in this Cochrane review,1 behavior interventions such as mailings, oral or dental screenings, group discussions, workplace interventions, and telephone support showed the best evidence for smokeless tobacco cessation. (Strength of Recommendation = B, based on inconsistent or limited quality patient-oriented evidence.) There was no benefit for the use of bupropion SR (Zyban) or nicotine patches or gum. (Strength of Recommendation = A, based on consistent and good quality patient-oriented evidence.)

Practice Pointers

The most common forms of smokeless tobacco are fine-grained “snuff ” that is usually placed between the lip and gum, and shredded chewing tobacco that is placed between the cheek and gum. Both methods of tobacco use allow absorption of nicotine through the oral mucosa. The 2005 National Health Interview Survey found that 20.9 percent of adults were current cigarette smokers, whereas 2.3 percent used smokeless tobacco.2 The Youth Risk Behavior Surveillance for 2007 found that 20 percent of adolescents in ninth through 12th grade used cigarettes, whereas 7.9 percent used smokeless tobacco.3

Patients may believe the use of smokeless tobacco is less harmful than cigarette smoking, but smokeless tobacco actually increases the risk of oral, esophageal, and pancreatic cancer. Up to 4 percent of oral cancers among U.S. men may be attributable to smokeless tobacco use.4 Although the cardiovascular risks of its use may not be as great as with cigarette use, smokeless tobacco users appear to have increased cardiovascular risk compared with nonusers.5

Because pharmacologic interventions (e.g., bupropion SR, varenicline [Chantix]) and nicotine replacement therapies (patch or gum) have shown some success in helping reduce cigarette use, it seems reasonable to assume these interventions also might work for cessation of smokeless tobacco. However, this Cochrane review demonstrates that the best current evidence most strongly supports behavior intervention and counseling.1

In studies with a follow-up of six months or longer, bupropion SR showed no advantage compared with placebo for smokeless tobacco cessation. Studies of nicotine replacement therapy also failed to demonstrate effectiveness compared with placebo. The review did not include studies of varenicline for smokeless tobacco cessation.

The studies of behavior interventions were heterogenous, but they demonstrated possible effectiveness in reducing smokeless tobacco use. Some of the studies of behavior intervention randomized participants at the organization level and included interventions such as employee-targeted interventions, mailings, posters hung in the workplace, oral screenings, school-based peer discussions, small group discussions, and telephone support. Other studies randomized participants at the individual level and included interventions such as routine dental visits, telephone support, counseling, and group discussions. The greatest treatment effects were found with interventions that included an oral examination (random-effects odds ratio [OR] = 1.92; 95% confidence interval [CI], 1.14 to 3.23) or telephone counseling (random-effects OR = 2.09; 95% CI, 1.68 to 2.61).

Cochrane Abstract

Background: Use of smokeless tobacco can lead to nicotine addiction, and long-term use can lead to health problems that include periodontal disease and cancer.

Objectives: To assess the effects of behavior and pharmacologic interventions for the treatment of smokeless tobacco use.

Search Strategy: The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March 2007.

Selection Criteria: Randomized trials of behavior or pharmacologic interventions to help users of smokeless tobacco to quit, with a follow-up of at least six months.

Data Collection and Analysis: Two authors independently extracted data.

Main Results: Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (odds ratio [OR] = 0.86; 95% confidence interval [CI], 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR = 1.16; 95% CI, 0.88 to 1.54), nor did two trials of nicotine gum (OR = 0.98; 95% CI, 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavior interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavior interventions, which include telephone counseling or an oral examination, may increase abstinence rates more than interventions without these components.

Authors' Conclusions: Behavior interventions should be used to help smokeless tobacco users to quit, and telephone counseling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinences.

These summaries have been derived from Cochrane reviews published in the Cochrane Database of SystematicReviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the originalreviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minorediting changes have been made to the text (

The U.S. Food and Drug Administration cautions that patients treated with bupropion SR should be watched closely for worsening of depression and increased suicidal thinking or behavior,6 and that serious neuropsychiatric symptoms have occurred in patients taking varenicline.7  Therefore, given the evidence supporting behavior interventions alone for smokeless tobacco cessation, the lack of evidence for pharmacologic or nicotine replacement strategies, and the potential adverse effects of pharmacologic interventions, the most appropriate strategy for helping a patient quit smokeless tobacco use is some form of behavior intervention. There are online resources available for physicians and patients to help with smokeless tobacco cessation (see accompanying table).

View/Print Table


Resources for Smokeless Tobacco Cessation

For physicians:

Centers for Disease Control and Prevention

Web site:

For patients:

American Academy of Family Physicians

Web site:


Web site:


Resources for Smokeless Tobacco Cessation

For physicians:

Centers for Disease Control and Prevention

Web site:

For patients:

American Academy of Family Physicians

Web site:


Web site:

Address correspondence to William E. Cayley, Jr., MD, at Reprints are not available from the author.

Author disclosure: Nothing to disclose.


show all references

1. Ebbert JO, Montori V, Vickers KS, Erwin PC, Dale LC, Stead LF. Interventions for smokeless tobacco use cessation Cochrane Database Syst Rev. 2007;(4):CD004306....

2. Centers for Disease Control and Prevention. Tobacco use among adults—United States, 2005. MMWR Morb Mortal Wkly Rep. 2006;55(42):1145–1148.

3. Eaton DK, Kann L, Kinchen S, et al., for the Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2007. MMWR Surveill Summ. 2008;57(4):1–131.

4. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol. 2008;9(7):667–675.

5. Gupta R, Gurm H, Bartholomew JR. Smokeless tobacco and cardiovascular risk. Arch Intern Med. 2004;164(17):1845–1849.

6. U.S. Food and Drug Administration. Bupropion hydrochloride (marketed as the antidepressant Wellbutrin) information. Accessed October 1, 2009.

7. U.S. Food and Drug Administration. Varenicline (marketed as Chantix) information. Accessed October 1, 2009.

The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Cayley presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at

The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.



Copyright © 2009 by the American Academy of Family Physicians.
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