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).

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).