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Efficacy of smokeless tobacco for smoking cessation: a systematic review and meta-analysis
  1. Daniel Stjepanović1,
  2. Preeti Phartiyal1,
  3. Janni Leung1,2,
  4. Carmen C W Lim1,
  5. Tianze Sun1,
  6. Jack Yiu Chak Chung1,
  7. Coral E Gartner3,4,
  8. Wayne D Hall1,4,
  9. Gary C K Chan1
  1. 1 National Centre for Youth Substance Use Research, The University of Queensland, Saint Lucia, Queensland, Australia
  2. 2 School of Psychology, The University of Queensland, Saint Lucia, Queensland, Australia
  3. 3 School of Public Health, The University of Queensland, Herston, Queensland, Australia
  4. 4 Queensland Alliance for Environmental Health Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Woolloongabba, Queensland, Australia
  1. Correspondence to Dr Daniel Stjepanović, National Centre for Youth Substance Use Research, The University of Queensland, Saint Lucia, Australia; d.stjepanovic{at}


Objective Smoking remains prevalent in many countries despite rigorous tobacco control strategies. The use of Swedish snus, a type of low-nitrosamine smokeless tobacco, has been promoted as a tobacco harm reduction strategy.

Data sources and study selection Three databases were searched for studies that assessed the effectiveness of snus in promoting smoking abstinence. A total of 28 studies were reviewed (5 randomised controlled trials (RCTs), 7 longitudinal and 16 cross-sectional studies).

Data extraction Separate meta-analyses were conducted by study type, pooling effect estimates where outcome measures and design were sufficiently comparable. Study details and quality assessment (Risk of Bias 2 for RCTs, Newcastle-Ottawa Scale for observational studies) are provided for each study.

Data synthesis While the meta-analysis of RCTs did not show a significant association between snus use and smoking cessation (risk ratio (RR)=1.33, 95% CI 0.71 to 2.47 and RR=0.62, 95% CI 0.27 to 1.41), the results of the meta-analysis of longitudinal cohort studies (RR=1.38, 95% CI 1.05 to 1.82, p=0.022) and cross-sectional studies (OR=1.87, 95% CI 1.29 to 2.72, p=0.001) indicated that use of snus was associated with an increased likelihood of quitting or having quit smoking. There was significant heterogeneity in the cross-sectional studies, and leave-one-out analysis indicated that the longitudinal cohort results were driven by one study. Most studies examined were subject to an elevated risk of bias.

Conclusion There is weak evidence for the use of snus for smoking cessation. Better RCTs and longitudinal studies are needed; meanwhile, existing cessation aids may be better placed than snus to promote abstinence.

  • cessation
  • non-cigarette tobacco products
  • harm reduction

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  • Twitter @jannileung, @cwernlim, @TianzeSun, @JackYCChung, @CoralGartner, @GaryCKChan

  • Contributors DS: conceptualisation; study registration and data extraction; writing initial draft. PP: conceptualisation; study registration and data extraction; writing initial draft. GC: funding acquisition, conceptualisation, statistical analysis, investigation, writing and review. JL: conceptualisation, statistical analysis, writing and review. JC and CL: data extraction; data quality assessment, review and editing. CEG and WDH: writing; review and editing. All authors contributed to the data interpretation, writing and revisions of the report and have full access to all data in the study.

  • Funding GC was funded by a National Health and Medical Research Council (NHMRC) Investigator Grant (GNT1176137). CEG was funded by NHMRC Centre of Research Excellence Grant. CL was funded by National Health and Medical Research Council Postgraduate Scholarship (GNT2005317). DS and WDH were funded by Department of Health, Australia. TS, JC and PP were funded by postgraduate scholarships provided by The University of Queensland.

  • Disclaimer The funders had no input into the design, implementation or running of the study, in the writing of the manuscript or decision to publish.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.