|Year : 2018 | Volume
| Issue : 4 | Page : 396-410
Smokeless tobacco cessation interventions: A systematic review
Suzanne Tanya Nethan1, Dhirendra Narain Sinha2, Kumar Chandan3, Ravi Mehrotra3
1 Division of Clinical Oncology, ICMR-National Institute of Cancer Prevention & Research, Noida, India
2 School of Preventive Oncology, Patna, India
3 WHO FCTC Global Knowledge Hub on Smokeless Tobacco, ICMR-National Institute of Cancer Prevention & Research, Noida, India
|Date of Submission||15-Dec-2017|
|Date of Web Publication||21-Jan-2019|
Dr Ravi Mehrotra
ICMR-National Institute of Cancer Prevention & Research, Plot I-7, Sector 39, Noida 201 301, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background & objectives: Smokeless tobacco (SLT) consumption is a global health issue with about 350 million users and numerous adverse health consequences like oral cancer and myocardial disorders. Hence, cessation of SLT use is as essential as smoking cessation. An update on the available literature on SLT cessation intervention studies is provided here.
Methods: Through an extensive literature search on SLT cessation intervention studies, using keywords such as smokeless tobacco, cessation, interventions, quitlines, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, mHealth, etc., 59 eligible studies were selected. Furthermore, efficacy of the interventions was assessed from the reported risk ratios (RRs) [confidence intervals (CIs)] and quit rates.
Results: Studies were conducted in Scandinavia, India, United Kingdom, Pakistan and the United States of America, with variable follow up periods of one month to 10 years. Behavioural interventions alone showed high efficacy in SLT cessation; most studies were conducted among adults and showed positive effects, i.e. RR [CI] 0.87 [0.7, 1.09] to 3.84 [2.33, 6.33], quit rate between 9-51.5 per cent, at six months. Regular telephone support/quitlines also proved beneficial. Among pharmacological modalities, nicotine lozenges and varenicline proved efficacious in SLT cessation.
Interpretation & conclusions: Globally, there is limited information available on SLT cessation intervention trials, research on which must be encouraged, especially in the low-resource, high SLT burden countries; behavioural interventions are most suitable for such settings. Appropriate training/sensitization of healthcare professionals, and school-based SLT use prevention and cessation programmes need to be encouraged.
Keywords: Behavioural - intervention - nicotine replacement therapy - smokeless tobacco - tobacco dependence - tobacco use cessation
|How to cite this article:|
Nethan ST, Sinha DN, Chandan K, Mehrotra R. Smokeless tobacco cessation interventions: A systematic review. Indian J Med Res 2018;148:396-410
|How to cite this URL:|
Nethan ST, Sinha DN, Chandan K, Mehrotra R. Smokeless tobacco cessation interventions: A systematic review. Indian J Med Res [serial online] 2018 [cited 2020 Aug 4];148:396-410. Available from: http://www.ijmr.org.in/text.asp?2018/148/4/396/250535
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 diseases.
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 dependence.' 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 Parties. However, the average implementation of Article 14, as reported in the Global Progress Report on Implementation of the WHO-FCTC in 2016, has not been significant, i.e. 50 per cent, between 2012 and 2016, as compared to the other substantive articles of the Convention. 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 use.
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 countries. 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 1].
|Figure 1: 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.|
Click here to view
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:
Studies performed for SLT cessation interventions; studies performed for cessation of both smoking and SLT but also reporting data specific to SLT cessation; those with the most recent results for consecutively reported studies; SLT cessation intervention studies performed either on adults or adolescents were included. Only English language literature was included.
Studies only for smoking cessation; studies for cessation of both smoking and SLT but not providing separate information for SLT cessation; literature reviews; repetitive data (example: extracts from already included Cochrane articles); articles on tobacco use screening and counselling; study protocols; studies with differing objectives; old published data for the same study; unavailability of the complete report for reference in case of lack of clarity of information in the abstract; documents in languages other than English, were excluded.
The current status of availability of the SLT dependence and cessation measures globally and the efficacy of each of the SLT cessation intervention was assessed based on the risk ratio (RR) [confidence intervals (CIs)] and quit rates reported for each of them in the various resultant studies.
| Results|| |
Behavioural interventions for smokeless tobacco (SLT) cessation
Twenty randomized controlled trials (RCTs) (case-control studies) on behavioural interventions for SLT cessation were reported; sixteen were conducted in the USA,,,,,,,,,,,,,,,, three in India,, while only one study was reported from Sweden. Most studies had majority of adult participants while three were conducted among the youth,,. Among the 19 studies having a follow up of six months or more, 10 studies reported statistically and clinically significant benefits with RR (CI) ranging between 1.33 (1.09, 1.63) and 3.84 (2.33, 6.33),,,,,,,,,, in five studies the CIs did not specify a clinical benefit but did not exclude one either, with an RR (CI) between 1.08 (0.84, 1.39) and 3.72 (0.79, 7.47),,,, and four studies had RRs just below or above one and relatively narrow CI suggesting no important benefit or harm i.e. RR (CI) from 0.87 (0.7, 1.09) upto 1.07 (0.87, 1.31),,,. Overall, the RR (CI) ranged from 0.87 (0.7, 1.09) to 3.84 (2.33, 6.33). The one case-control pilot study conducted by Jhanjee et al showed an RR (CI) of 1.80 (0.77, 4.25) at the end of three months of treatment [Table 1]. Therefore, the trials suggested a benefit of behavioural interventions in SLT cessation.
|Table 1: Details of the smokeless tobacco (SLT) cessation intervention randomized controlled trials (RCT) and cohort studies|
Click here to view
Twelve non-case-control studies employing behavioural interventions for SLT cessation interventions were found, among which eight had a follow up of six months or more,,,,,,, and four had a follow up of less than six months,,,. Of these, two studies were performed in India,, one in Pakistan and United Kingdom (UK) and the rest were done in the USA,,,,,. Among the group having intervention/follow up of less than six months, the quit rate ranged from eight per cent (at the end of one month, Gala et al) to 58 per cent (after 1.5 months, Fisher et al),. The quit rate of SLT users in the trials having a longer follow up of six months or more was between 9 per cent (at six months, Walsh et al) and 51.5 per cent (after 12 months, Mishra et al), [Table 2].
|Table 2: Details of smokeless tobacco cessation intervention non case-control studies|
Click here to view
National toll-free quitlines (NQLs): Telephone support has been shown to be efficacious in SLT cessation. Among the aforementioned studies, 10 RCTs conducted in the USA, in which telephone support formed part of the intervention showed their benefit, with RR (CI) ranging between 1.32 (0.94, 1.86) and 3.84 (2.33, 6.33) [Table 1],,,,,,,,,. Four non case-control studies,,, reported a beneficial effect of telephone support for SLT cessation. A quit rate of 20 per cent among SLT users at the end of 18 months of the quitline activity in Rajasthan (India), a voluntary activity of Rajasthan Cancer Foundation, was reported. A media campaign (comprising of quitline component) in Nebraska (USA) reported a quit rate of 11.5 per cent at the end of 12 months and Eakin et al(USA) reported a quit rate of 16 per cent at the end of three months in their multi-component behavioural intervention programmes including frequent telephone contact/counselling with the SLT users. Mushtaq et al reported a quit rate of 43 per cent at the end of seven months; however, the intervention also involved delivery of NRT in addition [Table 2].
Pharmacotherapy for SLT cessation
Nicotine replacement therapy (NRT): Fifteen RCTs on NRT for SLT cessation were found. Twelve trials were performed in the USA,,,,,,,,,,, while three were conducted in the UK among Bangladeshi-resident women,,. Except one, the rest of the studies had adult participants. Among the 12 studies from the USA with a follow up of six or more months, neither nicotine patch,,,, nor nicotine gum, increased abstinence; however, the five studies of nicotine lozenges showed increased SLT abstinence, with RR (CI) between 0.73 (0.34, 1.55) and 1.53 (1.12, 2.09),,,, [Table 1]. In the Bangladeshi Stop Tobacco Project, NRT proved effective among 419 Bangladeshi female resident SLT users of UK with RR (CI) of 4.93 (2.02, 2.00) at four weeks, whereas the opposite was noted for nicotine gum or patch among 239 and 130 Bangladeshi origin participants living in the UK,, [Table 1].
Five non-case-control studies on NRT usage for SLT cessation were found. All were conducted among adults and had a follow up period of six months or more. Only one study was performed in Sweden and the rest in the USA,,,. Three studies tested the efficacy of nicotine gum alone in SLT cessation,,, while one study employed nicotine lozenge; Mushtaq et al, utilised nicotine gums, patches and lozenges in their participants. A higher benefit of nicotine lozenge in SLT cessation was also observed by Ebbert et al, i.e. 47 per cent quit rate at six months. The quit rate for NRT in general in SLT cessation ranged from 7 to 47 per cent [Table 2].
Non-nicotine therapy: A total of six RCTs, three each for bupropion and varenicline for SLT cessation, were found, and all were conducted among adults. All the three bupropion-related studies,, were performed in the USA, with one having a follow up of less than six months and the other two having a follow up period of more than six months,; however, none of these studies showed a positive effect on tobacco abstinence. The three trials of varenicline, were conducted in Scandinavia, USA and India with one having a follow up of less than six months and the other two having a follow up period of more than six months. These studies showed increased tobacco abstinence rates at six months compared to placebo [Table 1]. A single non-case-control pilot study in USA reported a quit rate of 15 per cent among adult participants at the end of 12 wk of treatment with varenicline and 10 per cent at the end of six months of follow up.
| 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 strengthened.
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 pharmacotherapy,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,. The Cochrane review (2015) on the SLT cessation intervention trials also showed results along similar lines, with behavioural interventions proving most efficacious for SLT cessation. Another Cochrane review (2012) also suggested almost similar efficacy of behavioural interventions in both smoking and SLT cessation. 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). 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 al, and 2.6 per cent by Sarkar et al, 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, respectively. 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 this.
Quitlines and telephone support for SLT cessation have proven efficacious as noted in literature,,,,,,,,,,,,,. In a Cochrane review, 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 alone. However, according to the MPOWER 2017 data, 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 involved.
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). 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 enrolment. Based on the information from 12 studies reported in the Cochrane review, 2016 (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 MYTRI, 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.
Financial support & sponsorship: None.
Conflicts of Interest: None.
| References|| |
Singh PK. Smokeless tobacco use and public health in countries of South-East Asia region. Indian J Cancer
(Suppl 1) : S1-2.
WHO Framework Convention on Tobacco Control. Guidelines for Implementation of Article 14 of the WHO Framework Convention on Tobacco Control (Demand reduction Measures Concerning tobacco Dependence and Cessation). Available from: http://www.who.int/fctc/Guidelines.pdf
, accessed on May 4, 2017.
Raw M. Framework convention on tobacco control (FCTC) article 14 guidelines: A new era for tobacco dependence treatment. Addiction
Ebbert JO, Elrashidi MY, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev
2015; 10: CD004306.
Stevens VJ, Severson H, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment - a smokeless tobacco cessation intervention in the dental office. Am J Public Health
Cummings SR. An evaluation of a behavioural change intervention for smokeless tobacco use. Diss Abstr Int
Severson HH, Andrews JA, Lichtenstein E, Gordon JS, Barckley MF. Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial. J Am Dent Assoc
Walsh MM, Hilton JF, Masouredis CM, Gee L, Chesney MA, Ernster VL. Smokeless tobacco cessation intervention for college athletes: results after 1 year. Am J Public Health
Andrews JA, Severson HH, Lichtenstein E, Gordon JS, Barckley MF. Evaluation of a dental office tobacco cessation program: effects on smokeless tobacco use. Ann Behav Med
Cigrang JA, Severson HH, Peterson AL. Pilot evaluation of a population-based health intervention for reducing the use of smokeless tobacco. Nicotine Tob Res
Walsh MM, Hilton JF, Ellison JA, Gee L, Chesney MA, Tomar SL, et al
. Spit (smokeless) Tobacco Intervention for High School Athletes: results after 1 year. Addict Behav
Boyle RG, Pronk NP, Enstad CJ. A randomized trial of telephone counseling with adult moist snuff users. Am J Health Behav
Gansky SA, Ellison JA, Rudy D, Bergert N, Letendre MA, Nelson L, et al
. Cluster-randomized controlled trial of an athletic trainer-directed spit (smokeless) tobacco intervention for collegiate baseball athletes: Results after 1 year. J Athl Train
Severson HH, Andrews JA, Lichtenstein E, Danaher BG, Akers L. Self-help cessation programs for smokeless tobacco users: Long-term follow-up of a randomized trial. Nicotine Tob Res
Boyle RG, Enstad C, Asche SE, Thoele MJ, Sherwood NE, Severson HH, et al
. A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study. Nicotine Tob Res
Severson HH, Gordon JS, Danaher BG, Akers L. ChewFree.com: evaluation of a Web-based cessation program for smokeless tobacco users. Nicotine Tob Res
Severson HH, Peterson AL, Andrews JA, Gordon JS, Cigrang JA, Danaher BG, et al
. Smokeless tobacco cessation in military personnel: a randomized controlled trial. Nicotine Tob Res
Walsh MM, Langer TJ, Kavanagh N, Mansell C, MacDougal W, Kavanagh C, et al
. Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking. Nicotine Tob Res
Danaher BG, Severson HH, Andrews JA, Tyler MS, Lichtenstein E, Woolley TG, et al
. Randomized controlled trial of MyLastDip: a Web-based smokeless tobacco cessation program for chewers ages 14-25. Nicotine Tob Res
Danaher BG, Severson HH, Zhu SH, Andrews JA, Cummins SE, Lichtenstein E, et al
. Randomized controlled trial of the combined effects of Web and Quitline interventions for smokeless tobacco cessation. Internet Interventions
Gupta PC, Mehta FS, Pindborg JJ, Bhonsle RB, Murti PR, Daftary DK, et al.
Primary prevention trial of oral cancer in India: A 10-year follow-up study. J Oral Pathol Med
Stigler MH, Perry CL, Arora M, Shrivastav R, Mathur C, Reddy KS, et al.
Intermediate outcomes from project MYTRI: Mobilizing youth for tobacco-related initiatives in India. Cancer Epidemiol Biomarkers Prev
Jhanjee S, Lal R, Mishra A, Yadav D. A randomized pilot study of brief intervention versus simple advice for women tobacco users in an urban community in India. Indian J Psychol Med
Virtanen SE, Zeebari Z, Rohyo I, Galanti MR. Evaluation of a brief counseling for tobacco cessation in dental clinics among Swedish smokers and snus users. A cluster randomized controlled trial (the FRITT study). Prev Med
Walsh MM, Greene JC, Ellison JA, Letendre MA, Bergert N. A dental-based, athletic trainer-mediated spit tobacco cessation program for professional baseball players. J Calif Dent Assoc
: 365-72, 76.
Boyle RG, Stilwell J, Vidlak LM, Huneke JT. “Ready to quit chew?” Smokeless tobacco cessation in rural Nebraska. Addict Behav
Lichtenstein E, Andrews JA, Barckley M, Akers L, Severson HH. Women helping chewers: Partner support and smokeless tobacco cessation. Health Psychol
Mishra GA, Majmudar PV, Gupta SD, Rane PS, Uplap PA, Shastri SS, et al.
Workplace tobacco cessation program in India: A success story. Indian J Occup Environ Med
Meier E, Lechner WV, Miller MB, Wiener JL. Changes in smokeless tobacco use over four years following a campus-wide anti-tobacco intervention. Nicotine Tob Res
Mishra GA, Kulkarni SV, Majmudar PV, Gupta SD, Shastri SS. Community-based tobacco cessation program among women in Mumbai, India. Indian J Cancer
(Suppl 1) : S54-9.
Siddiqi K, Dogar O, Rashid R, Jackson C, Kellar I, O'Neill N, et al.
Behaviour change intervention for smokeless tobacco cessation: Its development, feasibility and fidelity testing in Pakistan and in the UK. BMC Public Health
Gupta R, Verma V, Mathur P. Quitline activity in Rajasthan, India. Asian Pac J Cancer Prev
Eakin E, Severson H, Glasgow RE. Development and evaluation of a smokeless tobacco cessation program: A pilot study. NCI Monogr
Masouredis CM, Hilton JF, Grady D, Gee L, Chesney M, Hengl L, et al.
A spit tobacco cessation intervention for college athletes: Three-month results. Adv Dent Res
Fisher KJ, Severson HH, Christiansen S, Williams C. Using interactive technology to aid smokeless tobacco cessation: A pilot study. Am J Health Educ
Gala S, Pesek F, Murray J, Kavanagh C, Graham S, Walsh M, et al.
Design and pilot evaluation of an internet spit tobacco cessation program. J Dent Hyg
Mushtaq N, Boeckman LM, Beebe LA. Predictors of smokeless tobacco cessation among telephone quitline participants. Am J Prev Med
Boyle RG. Smokeless tobacco cessation with nicotine replacement: A randomized clinical trial. Diss Abstr Int
Hatsukami DK, Jensen J, Allen S, Grillo MA, Bliss R. Effects of behavioral and pharmacological treatment on smokeless tobacco users. J Consult Clinical Psychol
Howard-Pitney B, Killen JD, Fortmann SP. Quitting chew: results from a randomized trial using nicotine patches. Exp Clin Psychopharmacol
Hatsukami DK, Grillo M, Boyle R, Allen S, Jensen J, Bliss R, et al
. Treatment of spit tobacco users with transdermal nicotine system and mint snuff. J Consult Clinical Psychol
Stotts RC, Roberson PK, Hanna EY, Jones SK, Smith CK. A randomised clinical trial of nicotine patches for treatment of spit tobacco addiction among adolescents. Tob Control
Ebbert JO, Dale LC, Patten CA, Croghan IT, Schroeder DR, Moyer TP, et al
. Effect of high-dose nicotine patch therapy on tobacco withdrawal symptoms among smokeless tobacco users. Nicotine Tob Res
Ebbert JO, Severson HH, Croghan IT, Danaher BG, Schroeder DR. A randomized clinical trial of nicotine lozenge for smokeless tobacco use. Nicotine Tob Res
Ebbert JO, Severson HH, Croghan IT, Danaher BG, Schroeder DR. A pilot study of mailed nicotine lozenges with assisted self-help for the treatment of smokeless tobacco users. Addict Behav
Ebbert JO, Severson HH, Croghan IT, Danaher BG, Schroeder DR. Comparative effectiveness of the nicotine lozenge and tobacco-free snuff for smokeless tobacco reduction. Addict Behav
Ebbert JO, Croghan IT, Schroeder DR, Hurt RD. A randomized phase II clinical trial of high-dose nicotine patch therapy for smokeless tobacco users. Nicotine Tob Res
Danaher BG, Severson HH, Crowley R, van Meter N, Tyler MS, Widdop C, et al
. Randomized controlled trial examining the adjunctive use of nicotine lozenges with MyLastDip: An eHealth smokeless tobacco cessation intervention. Internet Interv
Severson HH, Danaher BG, Ebbert JO, van Meter N, Lichtenstein E, Widdop C, et al
. Randomized trial of nicotine lozenges and phone counseling for smokeless tobacco cessation. Nicotine Tob Res
Croucher R, Shanbhag S, Dahiya M, Kassim S, McNeill A. Predictors of successful short-term tobacco cessation in UK resident female Bangladeshi tobacco chewers. Addiction
Croucher R, Shanbhag S, Dahiya M, Kassim S, Csikar J, Ross L, et al.
Smokeless tobacco cessation in South Asian communities: A multi-centre prospective cohort study. Addiction
(Suppl 2) : 45-52.
Croucher R, Islam S, Jarvis MJ, Garrett M, Rahman R, Shajahan S, et al.
Oral tobacco cessation with UK resident Bangladeshi women: A community pilot investigation. Health Educ Res
Wallström M, Bolinder G, Hassèus B, Hirsch JM. A cessation program for snuff-dippers with long-term, extensive exposure to Swedish moist snuff: A 1-year follow-up study. Acta Odontol Scand
Sinusas K, Coroso JG. Smokeless tobacco cessation: Report of a preliminary trial using nicotine chewing gum. J Fam Pract
Hatsukami DK, Edmonds A, Schulte S, Jensen J, Le CT, Losey L, et al.
Preliminary study on reducing oral moist snuff use. Drug Alcohol Depend
Ebbert JO, Dale LC, Severson H, Croghan IT, Rasmussen DF, Schroeder DR, et al.
Nicotine lozenges for the treatment of smokeless tobacco use. Nicotine Tob Res
Glover ED, Glover PN, Sullivan CR, Cerullo CL, Hobbs G. A comparison of sustained-release bupropion and placebo for smokeless tobacco cessation. Am J Health Behav
Dale LC, Ebbert JO, Schroeder DR, Croghan IT, Rasmussen DF, Trautman JA, et al
. Bupropion for the treatment of nicotine dependence in spit tobacco users: a pilot study. Nicotine Tob Res
Dale LC, Ebbert JO, Glover ED, Croghan IT, Schroeder DR, Severson HH, et al
. Bupropion SR for the treatment of smokeless tobacco use. Drug Alcohol Depend
Fagerstrom K, Gilljam H, Metcalfe M, Tonstad S, Messig M. Stopping smokeless tobacco with varenicline: randomised double blind placebo controlled trial. BMJ
Ebbert JO, Croghan IT, Severson HH, Schroeder DR, Hays JT. A pilot study of the efficacy of varenicline for the treatment of smokeless tobacco users in Midwestern United States. Nicotine Tob Res
Jain R, Jhanjee S, Jain V, Gupta T, Mittal S, Goelz P, et al.
A double-blind placebo-controlled randomized trial of varenicline for smokeless tobacco dependence in India. Nicotine Tob Res
Ebbert JO, Croghan IT, North F, Schroeder DR. A pilot study to assess smokeless tobacco use reduction with varenicline. Nicotine Tob Res
Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev
Kaur J, Sachdeva KS, Modi B, Jain DC, Chauhan LS, Dave P, et al.
Promoting tobacco cessation by integrating 'brief advice' in tuberculosis control programme. WHO South East Asia J Public Health
Sarkar BK, West R, Arora M, Ahluwalia JS, Reddy KS, Shahab L, et al.
Effectiveness of a brief community outreach tobacco cessation intervention in India: A cluster-randomised controlled trial (the BABEX trial). Thorax
Piné-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction
Raw M, Ayo-Yusuf O, Chaloupka F, Fiore M, Glynn T, Hawari F, et al.
Recommendations for the implementation of WHO framework convention on tobacco control article 14 on tobacco cessation support. Addiction
Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev
[Table 1], [Table 2]