Dr. Ebbert Spit Tobacco Presentation

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 &quot;high&quot; 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