What You Need to Know about Smokeless Tobacco Jon O. Ebbert, MD, MSc Assistant Professor of Medicine Mayo Clinic College of Medicine Rochester, MN
Goals & Objectives Understand the products Prevalence of use Health effects Neurobiology of smokeless tobacco use Marketing messages Current treatment
Understand the products
Prevalence of use
Health effects
Neurobiology of smokeless tobacco use
Marketing messages
Current treatment
Smokeless Tobacco: Definitions Chewing tobacco Loose leaf (i.e., Redman) Plugs Twists Snuff Moist (Copenhagen, Skoal) Dry (Honest, Honey bee, Navy, Square)
Chewing tobacco
Loose leaf (i.e., Redman)
Plugs
Twists
Snuff
Moist (Copenhagen, Skoal)
Dry (Honest, Honey bee, Navy, Square)
Chewing Tobacco
Snuff
Type of ST Used in U.S. National Survey on Drug Use and Health, 2003
Preferred Snuff Products National Survey on Drug Use and Health, 2003
Preferred Chewing Tobacco National Survey on Drug Use and Health, 2003
RJ Reynold’s
Phillip Morris (Altria)
Other ST Products USSTC Swedish Match, NA BAT
Scandinavian Snus
Scandinavian Snus
Results from the 2006 National Survey on Drug Use and Health: National Findings Past Month Tobacco Use among Persons Aged 12 or Older: 2002-2006
Prevalence ST use is higher in rural areas than in urban areas Rural counties 8.0% Large metropolitan areas 1.7% Differs by geographic area South 4.1% (highest) NE 1.5% (lowest) Lower among college graduates (2.2%) vs. high school completer/non-completers with no college (3.7%) 2004 National Survey on Drug Use and Health
ST use is higher in rural areas than in urban areas
Rural counties 8.0%
Large metropolitan areas 1.7%
Differs by geographic area
South 4.1% (highest)
NE 1.5% (lowest)
Lower among college graduates (2.2%) vs. high school completer/non-completers with no college (3.7%)
Health Impact of Smokeless Tobacco
ST - Health Consequences Report on Carcinogens, 10th Edition, National Toxicology Program, USDHHS Smokeless tobacco “ Known to be a human carcinogen”
Report on Carcinogens, 10th Edition, National Toxicology Program, USDHHS
Smokeless tobacco
“ Known to be a human carcinogen”
Health Effects: Cancers - U.S. Data Location OR (95% CI) Cancer, Mouth and Gum 11.2 (4.1-30.7) A Gum & Buccal Mucosa 4.2 (2.6-6.7) B Larynx 7.3 (2.9-18.3) A Salivary gland 5.3 (1.2-23.4) A Kidney 4.0 (1.2-12.9) C Pancreatic 3.6 ( 1.0-12.8) D A - Stockwell HG, et al. Head Neck Surg. 1986 Nov-Dec;9(2):104-10. B - Winn DM, et al. N Engl J Med. 1981 Mar 26;304(13):745-9. C - Goodman MT, et al. Am J Epidemiol. 1986 Dec;124(6):926-41. D - Muscat JE, et al. Cancer Epidemiol Biomarkers Prev. 1997 Jan; 6(1):15-9.
Location OR (95% CI)
Cancer, Mouth and Gum 11.2 (4.1-30.7) A
Gum & Buccal Mucosa 4.2 (2.6-6.7) B
Larynx 7.3 (2.9-18.3) A
Salivary gland 5.3 (1.2-23.4) A
Kidney 4.0 (1.2-12.9) C
Pancreatic 3.6 ( 1.0-12.8) D
ST Health Effects: CV Disease CPS-II *Current ST use vs. never associated with death from: All causes : HR 1.18 (95% CI: 1.08-1.29) CHD : HR 1.26 (95% CI: 1.08-1.47) Cerebrovascular dz : HR 1.40 (95% CI: 1.10-1.79) No difference between snuff and chewing tobacco Former use did increase the risk of death in any category Henley et al., Canc Cause Control. 2005; 16: 347-358. *Multivariate-adjusted
CPS-II
*Current ST use vs. never associated with death from:
All causes : HR 1.18 (95% CI: 1.08-1.29)
CHD : HR 1.26 (95% CI: 1.08-1.47)
Cerebrovascular dz : HR 1.40 (95% CI: 1.10-1.79)
No difference between snuff and chewing tobacco
Former use did increase the risk of death in any category
ST - Oral Lesions Leukoplakia Oral cancer Dental disease erosion of enamel dental caries Periodontal Disease gingival recession soft tissue/hard tissue loss gingivitis
Leukoplakia
Oral cancer
Dental disease
erosion of enamel
dental caries
Periodontal Disease
gingival recession
soft tissue/hard tissue loss
gingivitis
Tobacco-Related Oral Disease
Smokeless Tobacco Dependence
Volkow et al. J. Pharmacol. Exp. Ther. 291:409-415, 1999 The intensity of the "high" induced by methylphenidate is significantly correlated with the levels of released dopamine (r = 0.78, p <.001) . “ High” Intensity & Dopamine Release
Smokeless Tobacco Pharmacology Blood nicotine concentration (ng/ml) Benowitz, NL et al. Nicotine absorption and cardiovascular effects with smokeless tobacco use: comparison with cigarettes and nicotine gum. Clin Pharmacol Ther 1988; 44: 23-8. Benowitz NL, et al. Clin Pharmacol Ther. 1988 Jul;44(1):23-8. Figure Used with Permission from Elsevier.
ST Characteristics Affecting Nicotine Blood Levels Concentration of nicotine in ST product Size of the tobacco cuttings Long cut Fine cut (higher) Ammonium bicarbonate (additive) Lower acid level of product = higher free nicotine Acetic acid (additive) Increases salivation – enhances absorption Richter P, et al. Nicotine Tob Res. 2003 Dec;5(6):885-9.
Concentration of nicotine in ST product
Size of the tobacco cuttings
Long cut
Fine cut (higher)
Ammonium bicarbonate (additive)
Lower acid level of product = higher free nicotine
Acetic acid (additive)
Increases salivation – enhances absorption
CDC, 1999. Free Nicotine as a Function of pH
Impact of pH Manipulation Likelihood of choosing a brand with higher nicotine content is related to: Increasing duration of use Increasing intensity of use Frequency of ST use [Tomar, 1995 #2892] ST users who have used higher nicotine-containing products are more likely to report: More nicotine withdrawal symptoms Continued use because of difficulty quitting Tomar, SL, et al. Tob Control 4 : 67-72.
Likelihood of choosing a brand with higher nicotine content is related to:
Increasing duration of use
Increasing intensity of use
Frequency of ST use [Tomar, 1995 #2892]
ST users who have used higher nicotine-containing products are more likely to report:
More nicotine withdrawal symptoms
Continued use because of difficulty quitting
Frequency of Withdrawal Symptoms in 162 ST Users Ebbert JO, et al. Journal of Substance Abuse Treatment, 26 (4), 261-267.
Marketing Messages http://www.trinketsandtrash.org
Cowboy/Rodeo http://www.trinketsandtrash.org
Active Lifestyle http://www.trinketsandtrash.org
“ Social” Lifestyle http://www.trinketsandtrash.org
Individuality “ Not everybody understands it. Which is exactly why you do it.” http://www.trinketsandtrash.org
Brave New World – What’s a Smoker To Do? http://www.trinketsandtrash.org
Brave New World – What’s a Smoker To Do? http://www.trinketsandtrash.org
http://www.trinketsandtrash.org
Appeals to Females? http://www.trinketsandtrash.org
Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
Assist Set a quit date 2. Remove all tobacco products & memorabilia 3. Tell friends/family if and only if user is willing 3. Provide behavioral & pharmacologic support
Set a quit date
Behavioral Interventions Oral health feedback Advice to quit Materials + Set quit date & videos Severson HH et al. (1998). Journal of the American Dental Association, 129 (7), 993-999. Oral health feedback Presentation from coach Team support
Oral health feedback
Advice to quit
Materials
+ Set quit date & videos
Oral health feedback
Presentation from coach
Team support
If User Wants to Use Gradual Reduction Brand switching Copenhagen to Skoal Nicotine fading Reduce by 1-2 dips/day Quit at 50% of baseline Blending Snuff substitute mix 1/3 for 2 weeks, 2/3 for two weeks 100% snuff substitute Severson HH et al. (1999). Primary Care; Clinics in Office Practice, 26 (3), 529-551.
Brand switching
Copenhagen to Skoal
Nicotine fading
Reduce by 1-2 dips/day
Quit at 50% of baseline
Blending
Snuff substitute mix
1/3 for 2 weeks, 2/3 for two weeks
100% snuff substitute
Snuff Substitutes Smokey Mountain® Golden Eagle® Oregon Mint® KIK IT® Jerky® Bacc-Off®
Smokey Mountain®
Golden Eagle®
Oregon Mint®
KIK IT®
Jerky®
Bacc-Off®
Additional Tools Gum Hard candy Raisins Cinnamon sticks Toothpicks
Gum
Hard candy
Raisins
Cinnamon sticks
Toothpicks
Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
EMPHASIZE!!!! Nicotine is not what we fear – tobacco is the culprit Nicotine does not cause: Cancer Heart disease Communicate: “Smokeless tobacco is a nicotine delivery device and we are trying to prevent the side effects of this device” Oral disease Cancer
Nicotine is not what we fear – tobacco is the culprit
Nicotine does not cause:
Cancer
Heart disease
Communicate: “Smokeless tobacco is a nicotine delivery device and we are trying to prevent the side effects of this device”
Oral disease
Cancer
Recommended ST Treatment Approach 1) Behavioral treatment Oral examination +/- oral replacement products 2) Bupropion 150 mg po qd x 3 days then bid Quit 1 week later Continue for 3-6 months 3) Tailored nicotine patch therapy +/- gum/lozenge for self-titration
1) Behavioral treatment
Oral examination
+/- oral replacement products
2) Bupropion
150 mg po qd x 3 days then bid
Quit 1 week later
Continue for 3-6 months
3) Tailored nicotine patch therapy
+/- gum/lozenge for self-titration
Nicotine Lozenge Nicotine Polacrilex 2 mg 4 mg Dissolves in mouth over 20-30 minutes Delivers 25% more nicotine than the gum
Nicotine Polacrilex
2 mg
4 mg
Dissolves in mouth over 20-30 minutes
Delivers 25% more nicotine than the gum
Proper Lozenge Placement 4 NL
Goals & Objectives Understand the products Prevalence of use Health effects Neurobiology of smokeless tobacco use Marketing messages Current treatment
Understand the products
Prevalence of use
Health effects
Neurobiology of smokeless tobacco use
Marketing messages
Current treatment
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