Smokeless Tobacco Lesions Treatment & Management

Updated: Jun 25, 2018
  • Author: Carol E Cheng, MD; Chief Editor: William D James, MD  more...
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Medical Care

To reduce the risk of progression to oral cancer, smokeless tobacco use should be minimized, with cessation encouraged. The National Cancer Institute recommends that clinicians use the "4 A s," as follows:

  • Ask about tobacco use

  • Advise patients to quit smoking

  • Assist patients in quitting

  • Arrange follow-up

A 2010 study comparing the effectiveness of a 4-mg nicotine lozenge with behavior intervention compared with behavioral intervention alone reported no difference between groups for increasing tobacco abstinence, quit attempts, and duration of abstinence. [44]

The National Spit Tobacco Education Program (NSTEP) [45] is a national organization committed to minimizing the risk of oral cancers associated with smokeless tobacco through education. This organization does not advocate smokeless tobacco use as a healthier alternative to cigarette smoking. NSTEP targets education to the general public and specifically to baseball players and their families, in whom the use of smokeless tobacco is extremely high. In fact, NSTEP is supported and endorsed by both Major League Baseball and Little League Baseball.

In 2015, San Francisco became the first US city to ban the use of smokeless tobacco at sporting events, including AT&T Park, home of the city's Major League Baseball team, the Giants. Following step, four additional cities—New York, Boston, Los Angeles, and Chicago—are enacting similar measures. [46]

According to the most recent Cochrane review on interventions for smokeless tobacco use cessation, nicotine replacement therapy and bupropion have not been shown to affect long-term abstinence. Behavioral interventions should be used to help smokeless tobacco users to quit, and telephone counselling or an oral examination may increase abstinence rates. [47]


Surgical Care

Biopsy should be performed on lesions of erythroplasia that are suggestive of cancer based on their appearance or location in the oral cavity or those that have failed to resolve within 2-3 weeks. Premalignant lesions and carcinoma in situ (CIS) may be permanently cured after excision or biopsy. Primary and invasive squamous cell carcinomas (SCCs) are treated with varying combinations of surgery and/or radiation.

Once a diagnosis of oral cancer is established, the therapeutic approach is multidisciplinary.



Treatment for oral cancer may involve consultation with the following:

  • Dentist
  • Head and neck surgeon (otolaryngologist)
  • Maxillofacial surgeon
  • Radiation oncologist
  • Speech therapist
  • Surgical oncologist


Several studies have found that a diet low in fruits and vegetables is linked with an increased risk of cancers of the oral cavity and oropharynx. [48]

Cigarette, cigar, or pipe use at each time interval correlated with significantly increased caloric intake in males but not in females. In both males and females, tobacco users consumed more fat, cholesterol, and alcohol.



The National Spit Tobacco Education Program (NSTEP), with funding from the Robert Wood Johnson Foundation and other national organizations, advocates the prevention of smokeless tobacco use through education. Additionally, clinicians should use the "4 A s" proposed by the National Cancer Institute as outlined in Medical Care.


Long-Term Monitoring

Persons who use smokeless tobacco should have regular follow-up visits to their physician and dentist for oral examinations. Long-term monitoring for the development of new oral lesions is important for early detection and prevention of oral cancer.