Pharmacological Interventions for Cessation of Smokeless Tobacco Use

Smokeless tobacco (ST) use remains a significant global public health challenge, especially in low- and middle-income countries (LMICs), where it is culturally embedded and under-regulated. This chapter provides a comprehensive synthesis of the evidence on pharmacological interventions for ST cessation. It highlights the unique addiction profile of ST, characterized by prolonged mucosal nicotine absorption and sustained blood levels, necessitating tailored cessation strategies. Meta-analysis findings indicate that nicotine replacement therapy (NRT) and varenicline significantly improve cessation outcomes (RR = 1.13; 95%CI: 1.00–1.28 and RR = 1.23; 95%CI: 1.05–1.45, respectively), while evidence for bupropion remains inconclusive. Pharmacotherapies are generally safe and most effective when combined with behavioural support; yet such integrated approaches are rarely available in many high-burden settings. Importantly, oral health professionals are well positioned to play a frontline role in identifying ST users and initiating cessation intervention, given ST’s strong association with periodontal disease, oral cancers, and oral potentially malignant disorders. Barriers to offering ST cessation intervention include limited access to cessation medication, inadequate provider training, and weak policy inclusion of ST in national policy frameworks. This chapter underscores the urgent need to include pharmacotherapies for ST in essential medicine lists, national treatment guidelines, and primary care protocols. Regulatory reform, provider training, and integration into existing healthcare platforms, including oral and maternal and child health services, are critical to scale up cessation intervention. There are gaps in the evidence base, particularly among adolescents, pregnant women, and rural populations. There is also a pressing need for context-specific clinical trials, novel pharmacotherapeutic delivery systems, and implementation science. Advancing this agenda will require cross-sectoral collaboration. Ultimately, this chapter advocates for prioritizing ST cessation as a critical component of global tobacco control strategies, in alignment with the objectives of the World Health Organization Framework Convention on Tobacco Control. Pharmacological interventions, when equitably deployed and culturally tailored, offer a cost-effective strategy to reduce disease burden and promote oral and systemic health in high-risk populations.