Smokeless tobacco (ST) use is the practice of using incombustible tobacco products without smoking.^1,2 Available forms of ST are snuff, snus, heated tobacco products and chewing, oral or spitting tobacco,¹ and all of them contain nicotine.² The use of the snuff by quite a few patients attending one of the Pretoria day clinics has impacted the minds of a few medical doctors working in primary care in Pretoria to initiate this study.

The use of snuff was first recorded among American Indians to prevent fatigue and relieve hunger, as well as for ritual and ceremonial practices.² In ancient China, it was believed that snuff could induce sweating, cure toothache, and relieve constipation.² Snuff use became popular in Europe in the 16th–18th centuries, when it was often used by royalty.²

Tobacco use is responsible for approximately 15% of all global deaths – nearly nine million deaths annually.³ A recent systematic review on the health outcomes of ST use revealed overwhelming evidence that ST is associated with a variety of adverse health outcomes, especially in Africa, Asia and the Middle East.⁴ These outcomes include increased mortality rates, risk for a higher number of malignancies (such as oesophageal cancer and oral cancer),² coronary heart disease, stroke, hypertension and dyslipidaemia,^3,4 as well as dental and periodontal disease and adverse pregnancy outcomes.² In addition to these adverse effects, repeated tobacco use can lead to nicotine dependence,⁵ which in turn sustains the tobacco use.⁵ Consumers rely on tobacco to modulate mood and to give a sense of arousal,⁵ which is achieved by the release of dopamine and other neurotransmitters in the brain through the action of the nicotine on cholinergic neurotransmitters.⁵ As with other addictions, tobacco addiction or dependence is a disorder that requires not only more than acute but also follow-up care because of the vulnerability of users to relapse.⁵ A decreased nicotine level in the brain that results from discontinuation of tobacco use can lead to tobacco cravings that may maintain the urge to use the substance.⁵ This process is because of lower levels of dopamine being released in the brain. Dopamine is a neurotransmitter that leads to a temporary sensation of well-being; use of ST and smoking tobacco can trigger the release of dopamine within 20 seconds of ingestion.⁵

To quit using any form of tobacco is challenging.⁶ In adults who smoke tobacco, there is a 50% lifetime chance of quitting and 42% of consumers of ST will be unable to quit.⁶ All forms of smokeless tobacco use, including snuff, have been researched in the United States (US) to help individuals give it up. Behavioural assistance and medicine were the two main strategies.⁷ With medication approach, numerous studies employed different kinds of nicotine replacement therapy (two patches, five gum and five lozenges), yet the results showed that nicotine lozenges could aid in patients’ cessation; however, the quality of the evidence was poor, necessitating further investigation. The behavioural assistance included short instruction, self-help materials, phone support, online access and feature combinations. The results were wildly inconsistent, with some trials providing strong proof of benefit and others yielding no effect at all.⁷

In order to better support those who use snuff and visit the Ramotse clinic in Pretoria, this study aims to determine the motivations behind the use of ST, especially snuff, as well as their understanding of various cessation techniques and their readiness to stop using it.

Data on snuff usage in a semi-urban Pretoria region can be grouped in four points: (1) The sociodemographic data of the participants revealed that most of them were unemployed, married, mostly female, 40 years of age or older, and had only a basic education; (2) Motivations supporting the behaviour: when asked about the reasons that influenced their behaviour, most of them cited socio-cultural practices and behaviours as well as the health advantages that the goods they utilised offered; (3) In terms of awareness on tips that can help them quit the habit, most of them were unaware, and (4) when it came to ready to stop the behaviour, most of them were not ready.

From the sociodemographic viewpoint, there are some parallels to Nigerian research published in 2021¹¹ that looked at the prevalence, patterns, and correlates of ST use.¹¹ The most common kind of ST used in Nigeria was snuff by nose. And, while this survey did not compare the usage of the various varieties of ST, one of the studies on ST conducted in Ramotse has already indicated that snuff was the most common variety.¹ In terms of education, over half of the Nigerian sample had no formal education or had only completed basic school.¹¹ This is similar to the Ramotse study, in which more persons did not have more than elementary schooling. Contrary to the findings of the Ramotse survey, which revealed that females used snuff more frequently, research in Africa has shown that approximately 3% of men and 1% of women used ST on average between 2012 and 2022.¹² This is without any information on motives or awareness of tips to quit.

In 2019, the Truth Initiative produced a study on the prevalence of ‘every day’ or ‘someday’ ST usage by age group. When the Ramotes survey indicated greater usage among those aged 40 years and up, the Truth Initiative emphasised 3.7% for those aged 45 years and over, and the total computed proportion for those under 45 years was 5.4%. According to the research, these data change over time and between regions of the world.¹³ This statement accommodates whatever finding may occur elsewhere, including Ramotse.

Regarding the motives attached to the usage of snuff, this study found that socio-cultural practices or behaviours, followed by the health advantages provided by snuff, were the primary motivators for use. In Nigeria, research performed in 2021 found that socio-cultural structure was the primary factor for ST consumption. While exploring the purpose, subthemes such as ‘culture and living conditions’, ‘laws’, ‘family and peer connections’, ‘beliefs connected to psychological’ and ‘beliefs related to physical effects’, ‘beliefs’ emerged.¹⁴ Despite being part of a quantitative research, these socio-cultural practices and behaviours in Ramotse were more closely related to the participants’ culture, religion or spirituality, behaviour, and living situations.

In the US, after studying all ST usages, including snuff, using two approaches (medication and behaviour support), the evidence that nicotine lozenges may help patients quit the habit was low, whereas behaviour support in its variety of components demonstrated evidence of benefit, with others having no impact.⁷ Although the Ramotse survey was not experimental, some strategies such as nicotine replacement treatment, pharmaceutical concerns, and support were mentioned in the questionnaire. As was the case in America, most participants had not been exposed to these and were unaware of these strategies. As a result, further work is needed in both contexts to address the conduct. This revelation, in Ramotse, explains members’ desire to continue snuffing.

The study found that unemployed, married, mostly female, 40 years of age or older, and had a basic education match with the profile of participants. Socio-cultural practices and behaviours and health benefits influenced the habit. Most participants were unaware of tips to quit habits and unprepared to do so.