Interventions for Smokeless Tobacco Cessation

Are behavioral and pharmacotherapy interventions effective for smokeless tobacco cessation?

For people who use smokeless tobacco, counseling and brief advice are safe and effective in achieving tobacco cessation. (Strength of Recommendation [SOR]: A, consistent, good-quality patient-oriented evidence.) Nicotine replacement therapy (NRT) also increases cessation rates, although the evidence is less robust. (SOR: B, inconsistent or limited-quality patient-oriented evidence.) Varenicline (Chantix) is effective in helping people quit. (SOR: A, consistent, good-quality patient-oriented evidence.) Bupropion does not appear to aid in smokeless tobacco cessation.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

It is estimated that more than 5 million US adults currently use smokeless tobacco products.² Use is more prevalent among people who are uninsured and those with mental health disorders.² Long-term use of smokeless tobacco products is associated with an increased risk of stroke, esophageal cancer, and laryngeal cancer.³ Despite its prevalence and impact on health, smokeless tobacco products have been studied far less than smoked tobacco. This Cochrane review assessed behavioral and pharmacotherapy cessation interventions for smokeless tobacco use.¹

This Cochrane review involved 43 studies, mostly from North America (33 studies), including six from Asia and two from Scandinavia, with a total of 20,346 participants.¹ Eleven studies included adolescents and young adults, and 32 included only adults. Interventions were behavioral interventions with counseling (21 studies); brief advice (seven studies); and pharmacotherapy, including NRT (11 studies; patches, gum, or lozenges for 6–12 weeks), varenicline (two studies; 1 mg twice daily for 12 weeks), and bupropion (two studies; 150 mg twice daily for 12 weeks). The studied outcome was tobacco cessation at 6 months or longer follow-up. Harms were not assessed in this review, but there is a low likelihood of harm from behavioral interventions and well-established safety profiles for pharmacotherapy interventions.^4,5

More participants in the counseling group achieved tobacco cessation at more than 6 months of follow-up compared with those who received usual care or minimal cessation support for smokeless tobacco (relative risk [RR] = 1.76; 95% CI, 1.44–2.16; number needed to treat [NNT] = 9; 21 trials; n = 7,417; moderate-certainty evidence).¹ Brief advice also led to higher tobacco cessation rates at follow-up compared with no cessation support (RR = 1.24; 95% CI, 1.03–1.48; NNT = 28; seven trials; n = 6,271; moderate-certainty evidence).

NRT resulted in a greater number of participants achieving smokeless tobacco cessation compared with placebo or no medication (RR = 1.18; 95% CI, 1.05–1.33; NNT = 20; 11 trials; n =2,826; low-certainty evidence).¹ Although the meta-analysis of NRT interventions demonstrated a difference, the studies of NRT were inconsistent, and several smaller studies suggested NRT is not effective. Compared with placebo, varenicline also led to higher rates of smokeless tobacco cessation (RR = 1.35; 95% CI, 1.08–1.68; NNT = 8; two trials; n = 508; moderate-certainty evidence). Bupropion did not result in any apparent difference (low-certainty evidence).

Consistent with this Cochrane review, the World Health Organization also recommends behavioral interventions (eg, individual or group face-to-face counseling or telephone counseling) and pharmacotherapy (eg, NRT, varenicline) for smokeless tobacco cessation.⁶ Further research on smokeless tobacco cessation interventions is needed to address the evidence gap compared with combustible tobacco cessation interventions.