Substitution of smokeless tobacco for cigarettes in Buerger's disease does not prevent limb loss

Buerger's Disease, characterized by segmental, inflammatory, occlusive disease of the distal small and medium sized arteries, predominantly affects young men who are cigarette smokers. The disease may lead to ischemia, necrosis, and amputation of distal extremities; most patients have significant improvement in symptoms if smoking is discontinued. We report a patient who experienced progression of biopsy-proven Buerger's disease, after substituting smokeless tobacco for cigarettes. The patient's disease was severe enough to eventually require bilateral below-knee amputations. The association of smokeless tobacco with progressive limb ischemia should lead clinicians to discourage the substitution of smokeless tobacco for cigarette smoking in patients with Buerger's disease.