One small randomized trial of bupropion was included, but it found no effect on tobacco abstention (OR=1.00; 95% CI, 0.23–4.37). Another small RCT found an effect; however, it was excluded from the meta-analysis because subjects were followed for only 3 months. The meta-analysis also concluded that behavioral interventions appear to be effective for increasing tobacco abstinence rates. Results were heterogeneous, and study quality was mixed. One post-hoc finding appeared to show that most effective behavioral interventions were coupled with an oral exam with direct feedback.
Recommendations from others
The United States Department of Health and Human Services recommends that smokeless tobacco users should be treated with the same counseling and interventions utilized for smokers, but commented that evidence is currently insufficient to suggest that NRT increases long-term abstinence.7 British guidelines concluded that no evidence clearly shows that nicotine gum or patches are effective cessation aids for smokeless tobacco users.2
Clinical Commentary
NRT not recommended for smokeless users; try bupropion, behavioral therapy
Patrick O. Smith, PhD
Professor, Family Medicine, University of Mississippi Medical Center
Smokeless tobacco users are a special tobacco user population with a limited research base. Although it seems counterintuitive, nicotine replacement therapy (nicotine gum and the nicotine patch) is not recommended for this population. Using the tobacco use and quit history, treatment may include bupropion while employing standard behavioral therapies: intra-treatment social support, extra-treatment social support, and problem solving skills training. After setting a quit date, prepare the patient for the quit, and following the quit attempt focus on relapse prevention. Frequent follow-up visits provide intra-treatment social support and promotes development of extra-treatment (eg, telephone or computer based quit lines or individuals) social support while providing practical problem solving.