Key messages

• Counselling, brief advice, varenicline and nicotine replacement therapy may all be effective ways to help people quit using smokeless tobacco.

• We need more research from countries in South and Southeast Asia, where smokeless tobacco is most commonly used and where there are the most different kinds of smokeless tobacco.

What is smokeless tobacco?

Smokeless tobacco is tobacco that, instead of being smoked in a cigarette or pipe, is used by chewing, sniffing or holding in the mouth. Over 300 million people worldwide use smokeless tobacco, and it is most common in South and Southeast Asia. There are a lot of different kinds of smokeless tobacco, which take a variety of forms (e.g. plugs, loose-leaf, powders). They are often combined with a range of additional ingredients, such as betel leaf, areca nut, slaked lime and flavourings. This means that some kinds of smokeless tobacco are likely to be more harmful or addictive than others.

What might help people to stop using smokeless tobacco?

There are a range of potential quitting aids for smokeless tobacco, and most are already used to help people quit smoking. They include medicines like nicotine replacement therapy (which can take the form of gum, patches or lozenge), varenicline, bupropion, and cytisine. Other quit support not involving medicine could include counselling, self-help leaflets, or advice from a healthcare professional. In this review, we look at any kind of support for quitting smokeless tobacco.

What did we want to find out?

Unlike smoking, there is less evidence available on the best ways to quit using smokeless tobacco. Therefore, we wanted to bring together up-to-date information to see what forms of quitting support can help people to quit using smokeless tobacco. Because of how varied different kinds of smokeless tobacco are, we also wanted to see if there are differences in how well quit aids work for different kinds of smokeless tobacco.

What did we do?

We searched for studies looking at any way to help people quit using smokeless tobacco. We wanted to know how many people stopped using any kind of tobacco at least six months after the start of the study, and we only included studies in which the treatments people received were decided at random. This type of study usually gives the most reliable evidence about treatment effects.

What did we find?

We found 43 studies of 20,346 people that tested ways to help people quit using smokeless tobacco. Thirty-three studies took place in North America, two in Scandinavia, five in India, one in Pakistan and one in Turkey. One study took place across three countries: Bangladesh, India and Pakistan. Studies tested the following different kinds of quitting aids.

• Nicotine replacement therapy, varenicline and bupropion (all medicines often used to help people quit smoking).

• Counselling, where a healthcare professional or trained counsellor discusses why and how someone should quit using tobacco.

• Brief advice, where someone gives a short piece of advice (under 15 minutes) about the dangers of tobacco and why quitting is a good idea.

What are the results of our review?

• Counselling probably helps more people to quit smokeless tobacco use than minimal or no support. For every 100 people given counselling, 23 to 34 might successfully stop, compared with 16 people given minimal or no support.

• Brief advice about quitting probably helps more people to quit smokeless tobacco use than no support. For every 100 people given brief advice, 15 to 22 might successfully stop, compared with 15 people given no support.

• Varenicline probably helps more people to quit smokeless tobacco use than a placebo (dummy treatment) or no medicine. For every 100 people given varenicline, 36 to 56 might successfully stop, compared with 33 people given placebo.

• Nicotine replacement therapy may help more people to quit smokeless tobacco use than placebo or no medicine. For every 100 people given nicotine replacement therapy, 29 to 36 might successfully stop, compared with 27 people given placebo or no medicine.

• Bupropion may or may not help more people to quit smokeless tobacco use than placebo or no medicine. For every 100 people given bupropion, 10 to 28 might successfully stop, compared with 19 people given placebo.

We did not find enough studies of different kinds of smokeless tobacco to learn if they affect how well different quitting aids work.

What are the limitations of the evidence?

There were some concerns about the evidence we found that mean we should be cautious in interpreting our findings. Some of the studies used methods that may affect their findings, making them less reliable, and we found that for some quit aids we did not have enough information to rule out the potential for them working more or less than we found in our review.

How up to date is this evidence?

We included evidence published up to 16 February 2024.