What is the recommended treatment approach for a non-smoker using chewing tobacco?

Treatment Approach for Chewing Tobacco Users

All individuals using chewing tobacco should receive the same evidence-based cessation treatment as cigarette smokers: a combination of behavioral interventions plus pharmacotherapy to maximize quit rates. 1

Why Chewing Tobacco Users Need Treatment

• Smokeless tobacco (including chewing tobacco) increases the risk of all-cause mortality and is a cause of atherosclerotic cardiovascular disease (ASCVD), albeit to a lesser degree than cigarette smoking. 1
• Meta-analyses demonstrate that smokeless tobacco use is associated with increased risk of coronary heart disease events. 1
• Tobacco abstinence is recommended to reduce ASCVD risk regardless of the form of tobacco used. 1

Assessment at Every Visit

• Screen for tobacco use status at every healthcare visit and document it as a vital sign. 1
• Ask specifically: "Have you used any tobacco product in the past 30 days?" rather than just asking "Do you smoke?" since people are less likely to report tobacco use when asked the latter way. 1
• Assess willingness to make a quit attempt now. 1

Recommended Treatment Algorithm

Step 1: Advise to Quit

• Firmly advise the patient to quit at every visit using clear, strong, yet compassionate and nonjudgmental language. 1
• Personalize the advice to the patient's specific health concerns. 1

Step 2: Combination Pharmacotherapy (First-Line)

Preferred primary therapy options: 1, 2

1. Combination nicotine replacement therapy (NRT):

   • Nicotine patch (long-acting) PLUS a short-acting NRT (gum, lozenge, inhaler, or nasal spray for breakthrough cravings) 1, 2
   • This combination outperforms single NRT formulations with a relative risk of 1.25 for higher long-term quit rates 2
   • Long-term nicotine patch therapy (>14 weeks) combined with ad libitum NRT achieves a 36.5% abstinence rate at 6 months versus 23.4% for standard nicotine patch alone 1

2. Varenicline:

   • 1 mg twice daily for minimum 12 weeks 1, 3
   • Achieves 21.8% quit rate at 6 months, superior to bupropion (16.2%) and nicotine patch alone (15.7%) 3
   • May be considered over bupropion or NRT to increase cessation rates 1

Step 3: Behavioral Support (Essential Component)

• Combine pharmacotherapy with behavioral interventions—this combination increases quit rates to 15.2% versus 8.6% with brief advice alone. 4, 3
• Provide at least 4-8 counseling sessions with a trained tobacco treatment specialist. 1
• Brief counseling (even 3 minutes) focusing on: "Are you willing to quit now?" and "What worked or didn't work before?" 1
• Refer to telephone quitlines, which offer free counseling support. 1, 5

Step 4: Treatment Duration

• Minimum 12 weeks of pharmacotherapy for initial quit attempt. 1, 2
• Consider extended treatment duration beyond 14 weeks to promote continued cessation. 1, 2
• Long-term nicotine patch therapy (>14 weeks) is superior to shorter-term treatment. 1

Step 5: Follow-Up

• Assess smoking status and medication tolerability within 2-3 weeks of initiating therapy. 1
• Continue follow-up at no more than 12-week intervals. 1
• Nicotine withdrawal symptoms peak within 1-2 weeks before subsiding. 1

If Initial Treatment Fails

Try these approaches sequentially: 1

1. Switch to a first-line medication not previously used (e.g., if combination NRT failed, try varenicline) 1
2. Use combination pharmacotherapy: Nicotine patch + bupropion SR achieves 28.9% abstinence rate 1
3. Increase NRT dose: Higher-dose nicotine patch (≥25 mg/day) provides incremental benefit over standard dosing 1
4. Extend treatment duration beyond the initial 12-week course 1

Common Pitfalls to Avoid

• Do not rely on pharmacotherapy alone—the combination with behavioral support is essential for maximum efficacy. 2, 4
• Do not use single-agent NRT when combination NRT is available and more effective. 2
• Do not discontinue therapy prematurely before the recommended minimum 12-week treatment period. 2
• Do not assume chewing tobacco is safe—it requires the same aggressive treatment approach as cigarette smoking. 1
• Do not fail to arrange follow-up—early assessment within 2-3 weeks is critical for treatment success. 1

Special Considerations

• Bupropion and varenicline should be avoided in patients with brain metastases due to increased seizure risk. 1
• Nausea is a common side effect of varenicline and may require management. 1
• NRT at normal doses has not been shown to negatively affect wound healing. 1
• Dedicate trained staff to tobacco treatment in every healthcare system to facilitate cessation. 1