Treatments for spit tobacco use: a quantitative systematic review

The Risk of Hypertension and Other Chronic Diseases: Comparing Smokeless Tobacco with Smoking

BACKGROUND

In the past, studies have compared smokeless tobacco and non-tobacco users for the risk of various chronic diseases. The differences in the risk of chronic diseases between smokeless tobacco user and smokers have not been explored. The objective of this study is to estimate the risk of chronic diseases among smokeless tobacco users compared to smokers.

METHODS

The data were used from the Study on Global Ageing and Adult Health (SAGE) Wave-1, conducted in 2007-2008 in India. The study sample is the respondents who reported consuming any form of tobacco in last 1 month. The total sample size was 4,038 respondents. The odds ratio of chronic morbidities was estimated taking smokers as the reference category.

RESULTS

The odds ratios for (self-reported) diabetes, asthma, and hypertension were not significant for smokeless tobacco user compared to smoked tobacco users. The odds ratio of chronic lung diseases (CLDs) was significantly lower among smokeless tobacco users compared to smoked tobacco users. The odds ratio of hypertension (measured) combined with low education and belonging to lowest wealth quintiles were not significant for smokeless tobacco users compared to smoked tobacco users. Duration of the use of smokeless tobacco and quantity of use was found to have no significant relation with risk of chronic diseases as compared to smoking.

CONCLUSION

This study did not find the significantly higher risk of chronic morbidities except for CLD for smokeless tobacco users compared to smoked tobacco users. The study suggests that the use of any form of tobacco may have a similar risk of chronic diseases.

Knowledge, Attitude and Practice of Chewing Gutka, Areca Nut, Snuff and Tobacco Smoking Among the Young Population in the Northern India Population

Objective: The objective of the study was to determine the Knowledge, Attitude and Practice of chewing gutka,areca nut, snuff and tobacco smoking among the young population in the Northern India Population between the age of 15 to 22 years. Methods: The study was approved by the ethical committee. A total of 10 school and colleges located in the rural and urban areas was selected. A total of 1500 young individuals aged between 15 to 22 years were selected . A self-administered questionnaire was designed comprised of 14 closed ended questions about Knowledge, Attitude and Practice towards consumption of areca nut , gutka and tobacco smoking that were filled by the participants. Descriptive statistics were obtained and mean, standard deviation, frequency and percentages were calculated. Data was analyzed by using SPSS. Result: A total of 1050 out of 1500 students responded to the questionnaire. A total of 227 subjects agreed that they are consuming the tobacco. Out of this, 196 (86.34%) were boys and 31 (13.65%) were girls who agreed in consumption of tobacco product. Out of 196, 150 boys (76.5%) practices the habit of smoking 1 -5 times a day and 46 (23.4% ) practice the habit of chewing areca nut and gutkha 1 - 5 times a day. Out of 31 girls, 25 girls (80.6%) practices the habit of smoking 1 -5 times a day and 6 (19.4%) practice the habit of chewing areca nut and gutkha 1 - 5 times a day. Out of 740 subjects, 530 were boys and 210 girls have full knowledge of deleterious long term effects of tobacco consumption. Conclusion:The present study concluded that young population of North India lack Knowledge, Attitude and Practice regarding consumption of areca nut, gutka and tobacco smoking. Here is an urgent need to take effective steps, especially on launching community awareness programs for the school children and public to educate them about the consequences of tobacco use, and on assessing their effectiveness in curbing the problem.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to tobacco dependence and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialised register in June 2015.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration. We summarised outcomes as risk ratios (RRs). For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

We identified 34 trials that met the inclusion criteria, of which nine were new for this update, representing over 16,000 participants. There was moderate quality evidence from two studies suggesting that varenicline increases ST abstinence rates (risk ratio [RR] 1.34, 95% confidence interval (CI) 1.08 to 1.68, 507 participants). Pooled results from two trials of bupropion did not detect a benefit of treatment at six months or longer (RR 0.89, 95% CI 0.54 to 1.44, 293 participants) but the confidence interval was wide. Neither nicotine patch (five trials, RR 1.13, 95% CI 0.93 to 1.37, 1083 participants) nor nicotine gum (two trials, RR 0.99, 95% CI 0.68 to 1.43, 310 participants) increased abstinence. Pooling five studies of nicotine lozenges did increase tobacco abstinence (RR 1.36, 95% CI 1.17 to 1.59, 1529 participants) but confidence in this estimate is low as the result is sensitive to the exclusion of three trials which did not use a placebo control.Statistical heterogeneity was evident among the 17 trials of behavioural interventions: eight of them reported statistically and clinically significant benefits; six suggested benefit but with wide CIs and no statistical significance; and three had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by study design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. In a post hoc subgroup analysis, trials of behavioural interventions incorporating telephone support, with or without oral examination and feedback, were associated with larger effect sizes, but oral examination and feedback alone were not associated with benefit.In one trial an interactive website increased abstinence more than a static website. One trial comparing immediate cessation using nicotine patch versus a reduction approach using either nicotine lozenge or brand switching showed greater success for the abrupt cessation group.

AUTHORS' CONCLUSIONS

Varenicline, nicotine lozenges and behavioural interventions may help ST users to quit. Confidence in results for nicotine lozenges is limited. Confidence in the size of effect from behavioural interventions is limited because the components of behavioural interventions that contribute to their impact are not clear.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: October 2010.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We summarised as odds ratios. For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

Data from one study suggest that varenicline increases ST abstinence rates (Odds Ratio [OR] 1.6, 95% Confidence Interval (CI) 1.08 to 2.36) among Swedish snus users.Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (OR 0.86, 95% CI 0.47 to 1.57). Nicotine replacement therapy (patch, gum, and lozenge) was not observed to increase tobacco abstinence rates (OR 1.14, 95% CI: 0.91 to 1.42). There was statistical heterogeneity among the 14 trials of behavioural interventions; seven of them reported statistically and clinically significant benefits, four suggested benefit but with wide CIs, whilst two had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by the design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. Most trials included either telephone counselling, an oral examination and feedback about any ST induced mucosal changes, or both. In a post-hoc subgroup analysis there was some evidence that behavioural interventions which include telephone counselling might increase abstinence rates more than interventions with less contact. In one trial an interactive website increased abstinence more than a static website.

AUTHORS' CONCLUSIONS

Varenicline and behavioural interventions may help ST users to quit. Behavioural interventions incorporating telephone counselling or an oral examination are likely to increase abstinence rates.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components.

AUTHORS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.

Bupropion SR for the treatment of smokeless tobacco use

BACKGROUND

No pharmacotherapies have been shown to increase long-term (> or = 6 months) tobacco abstinence rates among smokeless tobacco (ST) users. Bupropion SR has demonstrated potential efficacy for ST users in pilot studies. We conducted a multicenter, randomized, double-blind, placebo-controlled, clinical trial to assess the efficacy and safety of bupropion SR for tobacco abstinence among ST users.

METHODS

Adult ST users were randomized to bupropion SR titrated to 150 mg twice daily (N=113) or placebo (N=112) for 12 weeks plus behavioral intervention. The primary endpoint was the 7-day point-prevalence tobacco abstinence rate at week 12. Secondary outcomes included prolonged and continuous tobacco abstinence rates, craving and nicotine withdrawal, and weight gain.

RESULTS

The 7-day point-prevalence tobacco abstinence rates did not differ between bupropion SR and placebo at the end treatment (53.1% versus 46.4%; odds ratio (OR) 1.3; p=0.301). The 7-day point-prevalence abstinence did not differ at weeks 24 and 52. The prolonged and continuous tobacco abstinence rates did not differ at weeks 12, 24, and 52. A time-by-treatment interaction was observed in craving over time with greater decreases in the bupropion SR group. At 12 weeks, the mean (+/-S.D.) weight change from baseline among abstinent subjects was an increase of 1.7 (+/-2.9)kg for the bupropion SR group compared to 3.2 (+/-2.7)kg for placebo (p=0.005).

CONCLUSIONS

Bupropion SR did not significantly increase tobacco abstinence rates among ST users, but it significantly decreased craving and weight gain over the treatment period.

Effect of chronic nicotine administration on the rat lung and liver: Beneficial role of melatonin

Cigarette smoking is common in societies worldwide and has been identified as injurious to human health. The current study was designed to investigate the protective effect of melatonin, a radical scavenger and antioxidant, on nicotine-induced oxidative stress and morphological changes in the lung and liver of the rats. Three groups of male rats (controls, nicotine-treated [0.5 mg/kg], and nicotine plus melatonin [10 mg/kg] were used in this study. Levels of lipid peroxidation (LPO) products, superoxide dismutase (SOD) and glutathione (GSH) activity were measured in the tissue homogenates. Immunohistochemical and histological changes were also examined. The results revealed an increase in LPO and decrease in both SOD and GSH activity in the lung and liver homogenates on nicotine-treated rats. Melatonin administration to nicotine-treated rats attenuated the increase in LPO products and restored the SOD activity and GSH levels. The immunohistochemical and histological examination demonstrated marked increase in the immunoreactivity of nitrotyrosine, a specific "footprint" of peroxynitrite, and tissue damage in the lung and liver of nicotine-administered animals. Again, melatonin treatment reduced both nitrotyrosine reactivity and tissue damage associated with nicotine administration. These results, along with previous observations, suggest that melatonin may be useful in combating free radical-induced oxidative stress and tissue injury that is a result of nicotine toxicity.

Metabolic and Cardiovascular Effects of Smokeless Tobacco

The nation's largest cigarette companies are selling more smokeless tobacco (ST) products as more cities and states pass smoke-free laws. ST use is already common and is expected to get more popular as a result of these recent changes. Unfortunately, the medical and public knowledge of its risks is inadequate. The literature on the cardiovascular side effects of ST is scant, and there are many controversies associated with its use, for various reasons. Study findings show that ST may modestly increase cardiovascular mortality and produces transient changes in heart rate and blood pressure; however, it does not increase the risk of atherosclerosis or myocardial infarction. The association between ST and diabetes, lipoproteins, and stroke is less clear. Quitting ST causes weight gain, but less so than smoking. Although ST appears to be associated with less cardiovascular risk than smoking, nicotine replacement therapy is a safer and more controlled substitute for smoking than ST; however, ST can be considered in high-risk smokers in whom medicinal nicotine replacement therapy has failed.

Measuring nicotine dependence among smokeless tobacco users

The objective of this study was to assess the concurrent validity of the FTQ-ST and the DIS-IV diagnosis of nicotine dependence among 68 adult ST users enrolled in a randomized, controlled clinical trial of bupropion SR. FTQ-ST scores were not found to differ between those with and without a current DIS-IV diagnosis of nicotine dependence (7.4+/-2.1 vs. 6.8+/-2.8, P=0.325). For all possible FTQ-ST cutoff scores, the observed agreement between the FTQ-ST and the DIS-IV was not found to be different from that expected due to chance. FTQ-ST total scores were positively correlated with serum cotinine (Spearman's r=0.40, P<0.001), amount of tobacco used (r=0.51 and r=0.41 for average dips/chews per day; average tins/pouches per week, respectively, P<0.001), and a reduced likelihood of abstinence at 3 months (OR=0.76, 95% C.I. 0.61-0.96; P=0.019). Participants meeting DIS-IV criteria had lower cotinine concentrations than those without this diagnosis (411+/-263 ng/ml vs. 493+/-246 ng/ml; P=0.042). Poor concordance was observed between the FTQ-ST and the DIS-IV in the assessment of nicotine dependence in ST users.

Socio-demographic correlates of betel, areca and smokeless tobacco use as a high risk behavior for head and neck cancers in a squatter settlement of Karachi, Pakistan

BACKGROUND

Head and neck cancers are a major cancer burden in Pakistan. They share a common risk factor profile including regular consumption of products of betel, areca and tobacco. Use of paan, chaalia, gutka, niswar and tumbaku is acceptable in Pakistan and is considered a normal cultural practice. This cross-sectional study was carried out to understand the relation of socio-demographic factors for the consumption of paan, chaalia, gutka, niswar and tumbaku in Pakistani population. Through systematic sampling, 425 subjects from a squatter settlement in Karachi were interviewed using a structured questionnaire. High risk behavior was defined as Daily use of any of the above products.

RESULTS

Daily use of all the substances except chaalia was higher among males compared to females. Chaalia use was higher among adolescents than adults while non-married consumed both chaalia and gutka more than married. Mohajir ethnicity had higher prevalence of paan, gutka and tumbaku use while Pathans had higher prevalence of niswar use.

CONCLUSION

Prevalence of use of chewable products is high in Pakistan with particularly high use of certain substances related with socio-demographic profiles. Industrially prepared products, chaalia and gutka, are gaining popularity among youth. Policies and focused interventions can be developed taking into consideration the preferred use of products among different socio-demographic groups.

Tobacco, oral cancer, and treatment of dependence

Tobacco dependence is recognised as a life-threatening disorder with serious oral health consequences which responds to treatment in the form of behavioural support and medication. While cigarette smoking is the most hazardous and prevalent form of tobacco use in the west, consideration also needs to be given to other forms such as bidi smoking in India, reverse smoking by several rural populations and use of snuff and chewing tobacco. The evidence that the use of tobacco is the major risk factor for oral cancer and potentially malignant lesions of the mouth is clear. Counseling to quit smoking is not applied in a systematic or frequent manner to people presenting with potentially malignant lesions of the oral cavity. This review makes recommendations for interventions by health professionals to encourage and aid cessation of tobacco use as a part of prevention of oral cancer.

Smokeless tobacco: an emerging addiction

Smokeless tobacco (ST) use is an important health issue in the United States, and chronic use leads to significant morbidity. ST users are exposed to levels of nicotine comparable with smokers and experience symptoms of nicotine withdrawal when attempting to stop. Clinical treatment of ST users requires an understanding of the unique characteristics of ST. This article reviews ST products, epidemiology, pharmacology, health risks, and treatment approaches.

Residential treatment for smokeless tobacco use: a case series

We developed and implemented a novel 8-day residential treatment program for smokeless tobacco (ST) use. A multidisciplinary team delivered behavioral treatment, nicotine patches were adjusted to achieve 100% replacement of baseline peak serum nicotine concentrations, and bupropion sustained-release was prescribed. Mean participant age (+/- SD) was 47.4 +/- 18.2 years. Mean nicotine patch dose at program end was 43.2 mg/day +/- 13.9 (range 14 to 66 mg/d). Median percent replacement by serum nicotine concentrations was 86.6% (IQR: 75-113.8%). At 1 year, the biochemically-confirmed (urine anabasine <2.0 ng/mL) self-reported 7-day point prevalence tobacco abstinence rate was 58% (14/24). A residential treatment program for ST users may be effective. More research is needed to replicate our findings and determine if comparable abstinence rates can be achieved with outpatient ST treatment programs using similar behavioral and pharmacotherapies.

Smokeless tobacco cessation guidelines for health professionals in England

Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and health problems including periodontal disease and oral cancer

OBJECTIVES

To assess the effects of behavioural and pharmacotherapeutic interventions to treat ST use.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register (February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966-February 2004), EMBASE (1988-January 2004), CINAHL (1982-February 2004), PsycINFO (1984-February 2004), Database of Abstract of Reviews of Effectiveness (DARE, The Cochrane Library, Issue 1, 2004).

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit, with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

One trial of bupropion did not detect a benefit of treatment after six months (Odds Ratio (OR) 1.00, 95% Confidence Interval (CI): 0.23 to 4.37). Three trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of eight trials of behavioural interventions included in the meta-analysis. Three trials showed significant benefits of intervention. In a post-hoc analysis the trials of interventions which included an oral examination and feedback about ST-induced mucosal changes had homogeneous results and when pooled showed a significant benefit (OR 2.41 95% CI: 1.79 to 3.24).

REVIEWERS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit. Pharmacotherapies have not been shown to affect long-term abstinence but larger trials are needed.

What have we learned from 20 years of research on smokeless tobacco cessation?

Although smoking cessation continues to get most of the attention from both researchers and practitioners, treatment for smokeless tobacco (SLT) dependence gets little consideration. The reasons are varied, but essentially smoking is more prevalent, has greater public health implications, and has been the subject of clean air laws and environmental issues that have focused the attention on a burned tobacco, thereby leaving SLT with scant public health attention. This is unfortunate, because the sales of SLT products, especially moist snuff, have increased consistently over the past decade; regular use of these products can result in oral cancer, other negative effects on oral health, and nicotine dependence or addiction. This article will review some unique issues of SLT use that affect cessation and the empirical research on interventions.

Bupropion sustained release for treatment of tobacco dependence

Tobacco use is a global pandemic. The most common pharmacological treatments of tobacco use and dependence include nicotine replacement therapy and nonnicotine medications. Bupropion sustained release (SR) is the only first-line nonnicotine medication recommended by the US Public Health Service Clinical Practice Guideline. Randomized controlled clinical trials have shown that bupropion SR doubles abstinence rates compared with placebo. Long-term treatment with bupropion SR may reduce or delay smoking relapse. Bupropion SR has an excellent adverse effect profile, although a risk exists for serious adverse effects such as seizures. The risk of serious adverse effects associated with bupropion SR can be reduced by careful selection of patients. This article reviews the evidence of efficacy and common adverse effects of bupropion SR and delineates the clinical characteristics of patients at higher risk for adverse effects when bupropion SR is prescribed for treatment of tobacco use and dependence.