Practice recommendations
- Nicotine replacement therapy may be useful for short-term treatment of cravings, but may not improve cessation rates among patients who use smokeless tobacco (B).
- Patients who use >3 cans of smokeless tobacco a day may need higher than normal doses (42 mg/day) of nicotine replacement therapy (B).
- Evidence is insufficient to support the routine use of bupropion (Zyban) for smokeless tobacco cessation. It should be initiated at the physician’s discretion (B).
Strength of recommendation (SOR)
- Good quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
Through with Chew Week” and the “Great American Spitout.” Do they ring a bell?
If you answered no, you’re not alone.
“Through with Chew Week” was established by the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) in 1989, but it hasn’t quite garnered the same kind of recognition as the American Cancer Society’s Great American Smokeout.
When it comes to tobacco use—and more importantly, cessation—smokeless tobacco just doesn’t generate the kind of attention that cigarette smoking does. In fact, smokeless tobacco’s low profile extends beyond talk of “smokeouts” and “spitouts” to research on effective ways to quit.
We found this out first-hand when we conducted a literature search of Medline, PubMed, and a number of other databases to learn which cessation methods have proven efficacy. What we learned is that not only is research on the subject of smokeless tobacco cessation limited, but there is no recommended medication therapy to help these patients quit. Specifically:
- Nicotine-replacement therapies have failed to demonstrate a clear benefit in smokeless tobacco cessation, but under-dosing may be a factor for some patients.
- Bupropion’s (Zyban) usefulness in smokeless tobacco cessation is unclear. Data, thus far, have been inconclusive.
- Varenicline’s (Chantix) usefulness in smokeless tobacco cessation is unknown. There are no published case reports or clinical trials on the subject.
Millions of “chew” users are at risk
Tobacco use is the leading preventable cause of premature death in the United States, with more than 440,000 Americans dying of tobacco-related disease each year.1 Cigarette smoking is by far the most common form of tobacco used; however, smokeless tobacco, also known as chew, spit tobacco, or snuff, is used by 8.2 million Americans.2 More men than women use tobacco products overall, and smokeless tobacco, in particular.2
Health risks include MI. Specific health risks associated with smokeless tobacco include cancer of the oral cavity and pharynx, oral and periodontal disease, tooth decay, and pregnancy-related problems.1 (See “Smokeless tobacco was to blame”)
In addition, an international, case-control study evaluating the risk of myocardial infarction associated with various forms of tobacco use found an increased risk of myocardial infarction associated with smokeless tobacco use compared to non-tobacco users (odds ratio [OR]=2.23; 95% confidence interval [CI], 1.41-3.52).3
Notably, smokeless tobacco users in the study who also smoked cigarettes had the highest risk of all tobacco users when compared to non-users (OR=4.09; 95% CI, 2.98-5.61). These findings demonstrate that nicotine dependence is detrimental to health—regardless of the form of tobacco used. Even more worrisome is the notion that risk may actually be increased when multiple forms of tobacco are used by the same patient.
Patients want medication to help them quit
Current guidelines for tobacco cessation recommend that patients using smokeless tobacco should be identified, urged to quit, and treated with counseling interventions.4 Despite this recommendation, many patients are interested in using a medication to aid them in their quit effort, and many physicians would like to prescribe medication to help patients succeed.
To that end, it seemed logical to us that the same treatments used for smoking cessation would also be effective for smokeless tobacco cessation, given that the underlying problem—despite the form of tobacco used—is nicotine dependence. So we did a literature review to determine the optimal treatment for smokeless tobacco cessation. Our search included: Medline (1950-2007), PubMed (1966-2006), International Pharmaceutical Abstracts (1970-2006), Science Direct, CINAHL, PsycArticles, and Dissertation Abstracts. We used the following search terms: smokeless tobacco, spit tobacco, chew tobacco, cessation, bupropion, nicotine, and nicotine replacement. (Searches in Medline for nicotine replacement therapy in smokeless tobacco cessation were limited to clinical trials.) What we found were a limited number of studies, which we’ve summarized here.
Nicotine patch is useful, but to what degree?
We reviewed four studies involving the use of a nicotine patch for smokeless tobacco cessation (TABLE 1). In chronological order:
Study #1: 15-mg patch. The first study to evaluate the nicotine patch was a randomized, double-blind, placebo controlled trial published in 1999. A 15-mg nicotine patch was used by approximately 420 patients.5 Patients included in the trial were at least 18 years of age, nonsmokers, and used at least 1 can of smokeless tobacco per week. The main outcome of this trial was cessation at 6 months.