Smokeless tobacco (SLT) is predominantly used orally (chewed, sucked, dipped, held in the mouth, etc.) or nasally, which results in absorption of nicotine and other chemicals across mucus membranes. Smokeless tobacco products are used in forms that vary greatly in appearance, emissions and composition of tobacco and non-tobacco constituents. The manufacturing of SLT products range in complexity from simple cured tobacco to elaborate products with numerous chemical ingredients. Ingredient selection and mode of use can vary based on geographic locality, ingredient availability, cultural/societal norms, and personal preferences.

In terms of manufacturing, SLT can be broadly divided into premade and custom-made products. Premade SLT products, which are made for sale and generally consumed as purchased (i.e., “ready-to-use”), can be subdivided into:

• Commercial products (i.e., moist snuff, snus, khaini) that are made in traditional manufacturing settings such as factories or production facilities
• Cottage products (toombak, nasway, mainpuri, mawa) that are made in non-traditional production environments (market stalls, shops, houses, etc.) and often sold in non-commercial packaging (paper or plastic bags; wrapped in paper)

Premade manufactured ST products are available in a wide variety of physical forms, including, but not limited to, twisted tobacco leaves, loose tobacco, ground tobacco, dry tobacco (dry snuff), tars (chimó), pastes (kiwam), dentifrices (creamy snuff, toothpowder), tobacco-containing chewing gums, and mixtures of tobacco and other materials (zarda, gutka). Manufactured ST products, such as moist snuff and snus, are available as loose tobacco or tobacco sealed in porous teabag-like sachets, which are easily inserted and removed from the mouth.

Smokeless tobacco population-based cessation interventions

Effective preventive and cessation interventions as well as public policy efforts have shown to reduce SLT use. School-based and community prevention programs produce short-term effects such as reduced rates of prevalence, experimentation, and intention to use.

Most cessation programs have been evaluated with adult SLT users; they show positive results for dental office interventions and clinical interventions involving multiple sessions and counselor support. Oral health professionals can be engaged as a “front line” in the prevention and treatment of SLT dependence. Models such as “Ask-Advise-Refer” should be adopted and implemented in health care systems.

The evidence suggests that pharmacologic aids such as nicotine replacement (e.g., patches, gum, or lozenges) can help reduce withdrawal symptoms and cravings in SLT users. Where available, medication may be helpful in reducing symptoms associated with quitting SLT use and, in the case of varenicline, increasing short-term quit rates. Additional research is needed on different types of interventions and programs among a diverse range of countries and groups.

Web-based programs may also be an effective alternative in countries that have widespread access to the Internet. Evidence indicates that the detrimental health effects of SLT use are not well known in low- and middle income countries. Educating the populations in low- and middle-income countries about the harmful effects of SLT through media and health care systems is essential.

Gender distribution (epidemiology of SLT use)

Patterns of SLT use indicate that SLT use rates appear to vary widely among youth and adults. Among youth, boys generally report more use than girls. Among adults, men generally have a higher prevalence than women, except in Bangladesh and Thailand in the South-East Asia Region; in a few African countries (such as South Africa and Sierra Leone); in Cambodia, Malaysia, and Vietnam in the Western Pacific Region; and in Barbados in the Americas Region.

Among youth, there is evidence of high prevalence (≥10%) either overall or by gender in the South-East Asia Region (boys in Bhutan, India, and Myanmar), the Eastern Mediterranean Region (Djibouti), the Americas Region (boys in Barbados, Dominica, and Grenada), the African Region (Botswana, Congo, Lesotho, and Namibia), and the Western Pacific Region (Cook Island boys).

Among adults, there is a high prevalence (≥10%) in the South-East Asia Region (Bangladesh, Bhutan, India, Myanmar, Nepal, and Sri Lanka), in the European Region (Norway, Sweden, Uzbekistan), the Eastern Mediterranean Region (Yemen), the African Region (in Madagascar overall; men in Algeria and Benin; and among women in Mauritania and South Africa), and the Western Pacific Region (in Micronesia overall and among men, and in Cambodia among women).

SOURCE:Smokeless Tobacco and Public Health: A Global perspective (NCI Monograph)