Additionally, recent evidence suggests it may be important to consider dosing nicotine replacement according to number of cans of smokeless tobacco the patient uses per week. Heavy smokeless tobacco users may require higher initial doses than routinely used for smoking cessation therapy (eg, 42 mg/day if >3 cans of smokeless tobacco/day used).8
Further clinical research is needed to validate this recommendation, as well as to give specific dosing recommendations.
Nicotine gum. Two issues come to mind when considering the research on nicotine gum. First, the studies had relatively small sample sizes and it’s possible that the studies were not properly designed to detect a difference between groups.6,7 Second, the concept of dosing nicotine gum based on the number of cans of smokeless tobacco used per day has not been explored.
Bupropion. Studies involving bupropion and smokeless tobacco cessation share several of the limitations we’ve just discussed. Differing results reported in the literature regarding bupropion’s effectiveness makes its potential benefit unclear. Use should be determined on a case-by-case basis with the understanding that it may—or may not—be useful in decreasing cravings or increasing abstinence rates.
Varenicline. There is currently no literature available to help us evaluate the usefulness of varenicline in smokeless tobacco cessation. The mechanism of action of varenicline is such that use in smokeless tobacco cessation is plausible. Again, consideration of patients on a case-by-case basis is warranted.
One size does not fit all
Although nicotine dependence is the underlying problem for patients who utilize smokeless tobacco, current literature does not support a “one-size-fits-all” approach to treatment of various forms of tobacco abuse. Further clinical investigations are needed to determine the true utility of bupropion and varenicline, as well as the appropriate dosing of nicotine replacement therapy when prescribed for smokeless tobacco cessation.