Smokeless tobacco cessation interventions: A systematic review

Smokeless tobacco (SLT) use, a form of tobacco consumed without combustion/burning, has become a global health issue with about 350 million users, maximally seen in the South-East Asian Region. Its use is associated with a myriad of adverse effects, with the major ones being oral cancer, myocardial infarction and other cardiovascular diseases1.

Article 14 of the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) deals with tobacco addiction and dependence treatment measures. It states that ‘each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence2.’ The formulation of this Article demonstrates the fact that the FCTC realizes the addictive potential of tobacco. Hence, the same came into existence at the Conference of the Parties 4 with the objective of development of effective treatment guidelines and measures to promote adequate treatment for tobacco dependence, by the member Parties3. However, the average implementation of Article 14, as reported in the Global Progress Report on Implementation of the WHO-FCTC in 20164, has not been significant, i.e. 50 per cent, between 2012 and 2016, as compared to the other substantive articles of the Convention5. According to the guidelines of Article 14, tobacco cessation has multiple dimensions to it, comprising behavioural interventions [brief advice, telephone counselling via national toll-free quitlines (NQLs)], pharmacotherapy, nicotine replacement therapy (NRT) and non-nicotine therapy - bupropion and varenicline, involvement of the healthcare system/healthcare workers, noting individual's tobacco use2.

In spite of widespread use and adverse health consequences of SLT, there is a dearth of evidence-based published literature on SLT cessation as compared to that on smoking cessation. A systematic review and meta-analysis available for SLT cessation intervention trials was the Cochrane review reporting data till 2015, majorly for studies performed in the United States of America (USA), with a few in the Scandinavian countries6. Here we provide a global update on the existing literature regarding studies on the demand reduction measures concerning SLT dependence and cessation, along with evidence-based discussion of the efficacy of each.

Material & Methods

To search the literature and systematically review the various demand reduction measures for SLT dependence and cessation, an online search strategy was performed since inception (1966) for PubMed to 2017, and the resultant data evaluated, as shown in Figure.

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Figure

Flow chart showing search strategy. ^*These were the number of articles which were chosen for screening of their abstracts after excluding other articles deemed irrelevant based on their titles.

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Extensive PubMed and Google literature search was performed using a combination of keywords such as smokeless tobacco, cessation, interventions, dependence, treatment, quitlines, behavioural, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, dentist, mHealth and mobile. This search produced 28,756 results, the titles of which were assessed and those not relevant were excluded. Abstracts of the remaining publications and full papers were reviewed to identify those that fulfilled the inclusion criteria. Among these, 59 articles were found to be of potential interest and were included.

The criteria for data selection, obtained from the search above, were as follows:

Results

Discussion

Globally, a dearth in the published literature regarding SLT cessation intervention trials has been observed (only for 3% WHO-FCTC ratified Parties, i.e. 5/179 Parties - Sweden, Norway, India, United Kingdom and Pakistan, apart from the USA). Further, a deficiency in the tobacco cessation support availability in most low-resource and high SLT burden Parties has been reported in the MPOWER 2017, which is required to be strengthened66.

Studies assessing the efficacy of SLT cessation interventions, especially behavioural interventions, must be carried out by all countries, especially those having a high burden of SLT consumption, as behavioural interventions have been found to have maximum benefit in SLT cessation as compared to pharmacotherapy7891011121314151617181920212223242526272829303132333435363738. The Cochrane review (2015) on the SLT cessation intervention trials also showed results along similar lines, with behavioural interventions proving most efficacious for SLT cessation6. Another Cochrane review (2012) also suggested almost similar efficacy of behavioural interventions in both smoking and SLT cessation67. The importance of behavioural intervention in the form of brief advice by healthcare professionals for successful SLT cessation has also been undermined and not much research has been performed. The Global Adult Tobacco Survey (GATS) performed in India, Bangladesh, Kenya, Pakistan, Thailand and Uganda reported a considerable variation while tobacco cessation counselling by health professionals (greater consideration for smokers than SLT users)68. Two trials in India have been performed successfully utilizing brief advice for tobacco cessation among both smokers and SLT users i.e. an overall quit rate of 67.3 per cent was reported by Kaur et al69, and 2.6 per cent by Sarkar et al70, however, the quit rate for SLT users has not been mentioned separately. There is also a lack of formal training for tobacco cessation among health profession students and school personnel, as seen in the Global Health Professions Student Survey and Global School Personnel Survey, respectively68. Hence, the same must be encouraged and expanded up to the grass root level, i.e. among health workers working in the villages. However, the likelihood of healthcare professionals giving brief advice will be more if tobacco use is recorded in the medical history; but only 20 per cent of countries follow this71.

Quitlines and telephone support for SLT cessation have proven efficacious as noted in literature79101213141617192228343539. In a Cochrane review6, the pooled risk ratio of 10 studies conducted in the USA, in which telephone support formed part of the intervention, indicated benefit in SLT cessation. It was also noted that a combination of oral examination and telephone support was more beneficial (RR- 2.07, CI-1.61, 2.66), than oral examination alone6. However, according to the MPOWER 2017 data66, only one-third, i.e. 31 per cent, Parties have NQLs, the establishment of which needs to be encouraged. In addition, the phone number of the quitlines could be mentioned on the SLT product packet health warnings. To ensure broader coverage, the primary healthcare system, services for treating tuberculosis and human immunodeficiency virus/acquired immunodeficiency syndrome, dental set-ups and non-communicable diseases programmes could also be involved72.

mHealth services for SLT cessation can be employed as an easy and cost-effective option, especially in the low-income group countries, for smoking cessation. Very few WHO-FCTC ratified countries have provided this facility (24 Parties)72. A national, bilingual mCessation programme (tobacco cessation through mobile text messages) was started in 2016 in India. Evaluation at the end of the first year, of more than 12,000 registered users, demonstrated an average quit rate of about seven per cent among both smokers and SLT users six months after enrolment66. Based on the information from 12 studies reported in the Cochrane review, 201673 (performed mostly in high-income countries such as USA, Australia, UK, Switzerland, New Zealand), smokers who received the mobile phone-based support were around 1.7 times more likely to quit than those who did not, proving this intervention efficacious, which could also be utilized for SLT cessation.

Most studies had adult participants. SLT prevention and cessation programmes must be facilitated in schools such as Project MYTRI24, especially among students of the lower strata of the society and with a higher early tobacco usage initiation tendency (smoking and/or SLT or both).

In conclusion, SLT cessation intervention-based research needs encouragement globally, especially in the low-income group countries which are deficient in tobacco cessation support. Behavioural interventions have been proven to be an efficacious and feasible modality for tobacco cessation in all settings (low and high resource). Sensitization and imparting of training regarding the same to health professionals and SLT use prevention and cessation-related school programmes need to be encouraged.