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Dr. Ebbert Spit Tobacco Presentation


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Dr. Ebbert form the Mayo Clinic in Rochester MN PowerPoint presentation about the negative health effects of smoking.

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Dr. Ebbert Spit Tobacco Presentation

  1. 1. What You Need to Know about Smokeless Tobacco Jon O. Ebbert, MD, MSc Assistant Professor of Medicine Mayo Clinic College of Medicine Rochester, MN
  2. 2. Goals & Objectives <ul><li>Understand the products </li></ul><ul><li>Prevalence of use </li></ul><ul><li>Health effects </li></ul><ul><li>Neurobiology of smokeless tobacco use </li></ul><ul><li>Marketing messages </li></ul><ul><li>Current treatment </li></ul>
  3. 4. Smokeless Tobacco: Definitions <ul><li>Chewing tobacco </li></ul><ul><ul><li>Loose leaf (i.e., Redman) </li></ul></ul><ul><ul><li>Plugs </li></ul></ul><ul><ul><li>Twists </li></ul></ul><ul><li>Snuff </li></ul><ul><ul><li>Moist (Copenhagen, Skoal) </li></ul></ul><ul><ul><li>Dry (Honest, Honey bee, Navy, Square) </li></ul></ul>
  4. 5. Chewing Tobacco
  5. 6. Snuff
  6. 7. Type of ST Used in U.S. National Survey on Drug Use and Health, 2003
  7. 8. Preferred Snuff Products National Survey on Drug Use and Health, 2003
  8. 9. Preferred Chewing Tobacco National Survey on Drug Use and Health, 2003
  9. 10. RJ Reynold’s
  10. 11. Phillip Morris (Altria)
  11. 12. Other ST Products USSTC Swedish Match, NA BAT
  12. 13. <ul><ul><li>Scandinavian Snus </li></ul></ul>
  13. 14. 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
  14. 15. Prevalence <ul><li>ST use is higher in rural areas than in urban areas </li></ul><ul><ul><li>Rural counties 8.0% </li></ul></ul><ul><ul><li>Large metropolitan areas 1.7% </li></ul></ul><ul><li>Differs by geographic area </li></ul><ul><ul><li>South 4.1% (highest) </li></ul></ul><ul><ul><li>NE 1.5% (lowest) </li></ul></ul><ul><li>Lower among college graduates (2.2%) vs. high school completer/non-completers with no college (3.7%) </li></ul>2004 National Survey on Drug Use and Health
  15. 16. Health Impact of Smokeless Tobacco
  16. 17. ST - Health Consequences <ul><li>Report on Carcinogens, 10th Edition, National Toxicology Program, USDHHS </li></ul><ul><li>Smokeless tobacco </li></ul><ul><li>“ Known to be a human carcinogen” </li></ul>
  17. 18. Health Effects: Cancers - U.S. Data <ul><li>Location OR (95% CI) </li></ul><ul><li>Cancer, Mouth and Gum 11.2 (4.1-30.7) A </li></ul><ul><li>Gum & Buccal Mucosa 4.2 (2.6-6.7) B </li></ul><ul><li>Larynx 7.3 (2.9-18.3) A </li></ul><ul><li>Salivary gland 5.3 (1.2-23.4) A </li></ul><ul><li>Kidney 4.0 (1.2-12.9) C </li></ul><ul><li>Pancreatic 3.6 ( 1.0-12.8) D </li></ul>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.
  18. 19. ST Health Effects: CV Disease <ul><li>CPS-II </li></ul><ul><ul><li>*Current ST use vs. never associated with death from: </li></ul></ul><ul><ul><ul><li>All causes : HR 1.18 (95% CI: 1.08-1.29) </li></ul></ul></ul><ul><ul><ul><li>CHD : HR 1.26 (95% CI: 1.08-1.47) </li></ul></ul></ul><ul><ul><ul><li>Cerebrovascular dz : HR 1.40 (95% CI: 1.10-1.79) </li></ul></ul></ul><ul><ul><li>No difference between snuff and chewing tobacco </li></ul></ul><ul><ul><li>Former use did increase the risk of death in any category </li></ul></ul>Henley et al., Canc Cause Control. 2005; 16: 347-358. *Multivariate-adjusted
  19. 20. ST - Oral Lesions <ul><li>Leukoplakia </li></ul><ul><li>Oral cancer </li></ul><ul><li>Dental disease </li></ul><ul><ul><li>erosion of enamel </li></ul></ul><ul><ul><li>dental caries </li></ul></ul><ul><li>Periodontal Disease </li></ul><ul><ul><li>gingival recession </li></ul></ul><ul><ul><li>soft tissue/hard tissue loss </li></ul></ul><ul><ul><li>gingivitis </li></ul></ul>
  20. 21. Tobacco-Related Oral Disease
  21. 22. Smokeless Tobacco Dependence
  22. 24. 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
  23. 25. 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.
  24. 26. ST Characteristics Affecting Nicotine Blood Levels <ul><li>Concentration of nicotine in ST product </li></ul><ul><li>Size of the tobacco cuttings </li></ul><ul><ul><li>Long cut </li></ul></ul><ul><ul><li>Fine cut (higher) </li></ul></ul><ul><li>Ammonium bicarbonate (additive) </li></ul><ul><ul><li>Lower acid level of product = higher free nicotine </li></ul></ul><ul><li>Acetic acid (additive) </li></ul><ul><ul><li>Increases salivation – enhances absorption </li></ul></ul>Richter P, et al. Nicotine Tob Res. 2003 Dec;5(6):885-9.
  25. 27. CDC, 1999. Free Nicotine as a Function of pH
  26. 28. Impact of pH Manipulation <ul><li>Likelihood of choosing a brand with higher nicotine content is related to: </li></ul><ul><ul><li>Increasing duration of use </li></ul></ul><ul><ul><li>Increasing intensity of use </li></ul></ul><ul><ul><li>Frequency of ST use [Tomar, 1995 #2892] </li></ul></ul><ul><li>ST users who have used higher nicotine-containing products are more likely to report: </li></ul><ul><ul><li>More nicotine withdrawal symptoms </li></ul></ul><ul><ul><li>Continued use because of difficulty quitting </li></ul></ul>Tomar, SL, et al. Tob Control 4 : 67-72.
  27. 29. Frequency of Withdrawal Symptoms in 162 ST Users Ebbert JO, et al. Journal of Substance Abuse Treatment, 26 (4), 261-267.
  28. 30. Marketing Messages
  29. 31. Cowboy/Rodeo
  30. 32. Active Lifestyle
  31. 33. “ Social” Lifestyle
  32. 34. Individuality “ Not everybody understands it. Which is exactly why you do it.”
  33. 35. Brave New World – What’s a Smoker To Do?
  34. 36. Brave New World – What’s a Smoker To Do?
  35. 37.
  36. 38. Appeals to Females?
  37. 39. Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
  38. 40. Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
  39. 41. Assist <ul><li>Set a quit date </li></ul>2. Remove all tobacco products & memorabilia 3. Tell friends/family if and only if user is willing 3. Provide behavioral & pharmacologic support
  40. 42. Behavioral Interventions <ul><li>Oral health feedback </li></ul><ul><li>Advice to quit </li></ul><ul><li>Materials </li></ul><ul><li>+ Set quit date & videos </li></ul>Severson HH et al. (1998). Journal of the American Dental Association, 129 (7), 993-999. <ul><li>Oral health feedback </li></ul><ul><li>Presentation from coach </li></ul><ul><li>Team support </li></ul>
  41. 43. If User Wants to Use Gradual Reduction <ul><li>Brand switching </li></ul><ul><ul><li>Copenhagen to Skoal </li></ul></ul><ul><li>Nicotine fading </li></ul><ul><ul><li>Reduce by 1-2 dips/day </li></ul></ul><ul><ul><li>Quit at 50% of baseline </li></ul></ul><ul><li>Blending </li></ul><ul><ul><li>Snuff substitute mix </li></ul></ul><ul><ul><li>1/3 for 2 weeks, 2/3 for two weeks </li></ul></ul><ul><ul><li>100% snuff substitute </li></ul></ul>Severson HH et al. (1999). Primary Care; Clinics in Office Practice, 26 (3), 529-551.
  42. 44. Snuff Substitutes <ul><li>Smokey Mountain® </li></ul><ul><li>Golden Eagle® </li></ul><ul><li>Oregon Mint® </li></ul><ul><li>KIK IT® </li></ul><ul><li>Jerky® </li></ul><ul><li>Bacc-Off® </li></ul>
  43. 45. Additional Tools <ul><li>Gum </li></ul><ul><li>Hard candy </li></ul><ul><li>Raisins </li></ul><ul><li>Cinnamon sticks </li></ul><ul><li>Toothpicks </li></ul>
  44. 46. Methods of Treating Smokeless Tobacco Use Behavioral Pharmacologic
  45. 47. EMPHASIZE!!!! <ul><li>Nicotine is not what we fear – tobacco is the culprit </li></ul><ul><li>Nicotine does not cause: </li></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Heart disease </li></ul></ul><ul><li>Communicate: “Smokeless tobacco is a nicotine delivery device and we are trying to prevent the side effects of this device” </li></ul><ul><ul><li>Oral disease </li></ul></ul><ul><ul><li>Cancer </li></ul></ul>
  46. 48. Recommended ST Treatment Approach <ul><li>1) Behavioral treatment </li></ul><ul><ul><li>Oral examination </li></ul></ul><ul><ul><li>+/- oral replacement products </li></ul></ul><ul><li>2) Bupropion </li></ul><ul><ul><li>150 mg po qd x 3 days then bid </li></ul></ul><ul><ul><li>Quit 1 week later </li></ul></ul><ul><ul><li>Continue for 3-6 months </li></ul></ul><ul><li>3) Tailored nicotine patch therapy </li></ul><ul><ul><li>+/- gum/lozenge for self-titration </li></ul></ul>
  47. 49. Nicotine Lozenge <ul><li>Nicotine Polacrilex </li></ul><ul><ul><li>2 mg </li></ul></ul><ul><ul><li>4 mg </li></ul></ul><ul><li>Dissolves in mouth over 20-30 minutes </li></ul><ul><li>Delivers 25% more nicotine than the gum </li></ul>
  48. 51. Proper Lozenge Placement 4 NL
  49. 52. Goals & Objectives <ul><li>Understand the products </li></ul><ul><li>Prevalence of use </li></ul><ul><li>Health effects </li></ul><ul><li>Neurobiology of smokeless tobacco use </li></ul><ul><li>Marketing messages </li></ul><ul><li>Current treatment </li></ul>