1. Tobacco Module 4 Smokeless Tobacco Dental Health Intervention
Electronic Cigarettes
KAMU
Kansas Association for the Medically Underserved

2. Goals: Tobacco Cessation Training Community Health Clinics
Module 1: Why is it Hard to Quit?
Module 2: Ask, Advise, Assist, Refer
Module 3: Quit Smoking Medications
Module 4: Smokeless Tobacco, Dental Health Intervention and E-cigarettes
Module 5: Office Systems and Creating a Quit Plan
Babalola Faseru, MD, MPH
Department of Preventive Medicine and Public Health
University of Kansas Medical Center

3. Types of Smokeless Tobacco
Objectives
Types of Smokeless Tobacco
Prevalence, Health Effects, and How to Treat
“Ask, Advise, Refer” Model for Dental Practice
E-cigarettes
What we know
What we don’t know
What do you tell your patients

4. Smokeless Tobacco Harmful & Highly Addictive
Babalola Faseru, MD, MPH
Department of Preventive Medicine and Public Health
University of Kansas Medical Center
Smokeless Tobacco Harmful & Highly Addictive

5. Types of smokeless tobacco
Snus (snoose)—Scandinavian
moist powder tobacco product (place under upper lip—less need to spit)
Snus—American
similar to Scandinavian but no regulation
Dipping tobacco
moist snuff (lower lip and gums) causes excess saliva, could require spitting
Nasal Snuff
Finely ground dry form of tobacco “snuffed” through the nose
Chewing tobacco
long strands placed between cheeks, gum, or teeth (plugs, wads, chew)
Dissolvables
strips, sticks, orbs and compressed tobacco lozenges

6. HEALTH EFFECTS OF Smokeless tobacco
Cancer Risk
Smokeless tobacco contains 28 carcinogens
Increases the risk of developing several cancers
Oral Health Dangers
Increases the risk of developing precancerous mouth lesions
Strongly associated with recession of the gums.
Heart Disease and Stroke
Strongly associated with heart disease and stroke
Addiction
Use leads to nicotine addiction and dependence
Leukoplakia

7. Snus by Andreas Hagerman
NICOTINE & Smokeless “Holding an average-size dip in your mouth for 30 minutes gives you as much nicotine as smoking three cigarettes. A 2-can-a-week snuff dipper gets as much nicotine as a 1-1/2 pack-a-day smoker does.”
Two
main types of
smokeless tobacco
in the U.S.
Chewing Tobacco
Snuff
Snus by Andreas Hagerman

8. Smokeless tobacco USE in Kansas 2010-2011
Gender differences
Ethnic differences (high school)
Adult:
Males:
Dual use: 13.3%
Exclusively: 5.3%
Females: <1%
High school students:
Male: 15.5%; Females: <2%
Middle school students:
Males: 4.1%; Females: <2%
African Americans 10.5%
Caucasian 9.3%
Other race 7.0%
Kansas Tobacco Youth Survey, 2010;
Kansas BRFSS Tobacco and Adult Report, 2011;

9. Tobacco Company Marketing to youth
Chewing Tobacco Candy by Zombieite

10. ST treatment Strategy is different
Smokeless Dependence
Tobacco Dependence
Normal dip or chew contains 3.6 to 4.5 mg nicotine
Nicotine in dip or chew takes 30 minutes for the nicotine to be absorbed into system
With ST, nicotine continues to be absorbed 60 minutes after the tobacco is removed
Cigarette contains 1.8 mg nicotine
Nicotine from cigarette drag takes 7 seconds to reach brain and dopamine release
Once cigarette is extinguished, individual is no longer receiving nicotine

11. Encourage counseling
Identify triggers
Modify behaviors that increase risk for relapse
Evidence-based treatment for adults Combination of behavioral treatment and NRT is most effective

12. Evidenced-based Treatment for Adults
Nicotine Replacement Therapy (NRT)
The dose is based on amount of Smokeless Tobacco used/week:
The Nicotine Patch
If > 3 cans or pouches of tobacco per week:
Then prescribe a 42 mg patch dose (two 21 mg patches) daily for 4-8 weeks*
If 2-3 cans or pouches of tobacco per week:
Then prescribe the 21 mg patches daily for 4-8 weeks*
If < 2 cans or pouches of tobacco per week:
Then prescribe the 14 mg patches daily for 4-8 weeks*
*If patient reports no withdrawal/craving, then taper doses in 7-14 mg steps every 2-4 weeks.
Ebbert JO, et al. Effect of high-dose nicotine patch therapy on tobacco withdrawal symptoms among smokeless tobacco users. Nicotine Tob Res. 2007;9:43–52.
Nicotine Patch for Smokeless Tobacco Users, J. Ebbert et al. Nicotine and Tobacco Research; July 2013

13. Nicotine Lozenge or Gum to control cravings and withdrawal symptoms
If the first dip < 30 minutes of awakening, or patient is using >3 cans or pouches of tobacco per week:
Prescribe 4 mg Nicotine lozenge (1-2 pieces) every 1-2 hours as needed
If the first dip of the day is > 30 minutes after awakening or patient is using <3 cans or pouches of tobacco per week:
Prescribe 2mg Nicotine lozenge (1-2 pieces) every 1-2 hours as needed
Limit use to no more than 20 lozenges/day for up to 12 weeks. Taper as needed to control cravings and withdrawal symptoms.
If the first dip < 30 minutes of awakening, or patient is using >3 cans or pouches of tobacco per week:
Prescribe 4 mg Nicotine gum (1-2 pieces) every 1-2 hours as needed
If the first dip of the day is > 30 minutes after awakening or patient is using <3 cans or pouches of tobacco per week:
Prescribe 2 mg Nicotine gum (1-2 pieces) every 1-2 hours as needed
Limit to pieces of gum per day. Taper as needed to control cravings and withdrawal symptoms.
Ebbert JO, et al. Effect of high-dose nicotine patch therapy on tobacco withdrawal symptoms among smokeless tobacco users. Nicotine Tob Res. 2007;9:43–52.
Nicotine Patch for Smokeless Tobacco Users, J. Ebbert et al. Nicotine and Tobacco Research; July 2013

14. Combination NRT Therapy
Nicotine gum or the nicotine lozenge can be used as needed in combination with the nicotine patch to provide additional control of withdrawal symptoms and cravings.
Nicotine gum photo:

15. Other medications
Proven to help quit smoking, jury still out for smokeless:
Bupropion SR: either in combination with NRT products or as monotherapy.
Varenicline: either in combination with NRT products or as monotherapy.

16. Dental Health Intervention WHY SHOULD DENTAL PRACTICES INTERVENE?
Leukoplakia (oral precancer) on floor of mouth and tongue
Dental Health Intervention WHY SHOULD DENTAL PRACTICES INTERVENE?

17. Cigarettes and Smokeless harm dental health
Tobacco - major risk factor
oral cancers
periodontal disease, bone and attachment loss
Cigarette smoking slows healing
during periodontal treatment
significantly associated with implant failure

18. Adam comes to the Dental Clinic
He is 24
He has never seen a dental hygienist
His workplace is smoke-free
Adam likes to use snus because no one can see it and he doesn't need to spit
Adam’s girlfriend complains of his bad breath
He likes to use a new snus pouch every 3 hours
Note: Adam’s dad used moist snuff for 30 years
How can you address Adam’s tobacco addiction?

19. Dental Health Professional Ask, advise, refer model
ASK: “I see from your health history that you use tobacco.”
“I’d like to show you some changes in your mouth that were caused by your tobacco use.”
ADVISE: “You should stop smoking/using smokeless. Quitting tobacco is one of the most important things you can do to improve your oral health.”
REFER: “I’d like to arrange a visit in our medical clinic to see about medications to help you quit. Here is the KANQUIT Quitline number for free, excellent coaching on quitting.”
American Dental Hygienists Association;

20. Dental and medical clinics Can work together to help tobacco users quit
Dental Clinic (AAR)
Medical Clinic (AAAR)
Ask about tobacco use
Advise to quit
Refer to…
Medical clinic provider for medication
KS Quitline
Ask about tobacco use
Advise to quit
Assist with medication
Refer to KS Quitline

21. e-cigarettes
what’s the buzz?

22. Electronic cigarettes
Hand-held devices that mimic the act of smoking
Do not contain tobacco
Battery heats device and makes the tip glow
The user inhales vapor
nicotine, H20, anything else manufacture wants to put in or fails to clean out
“Vaping”
Howstuffworks.com

23. E-Cigarette Use Current users
US Adults: “E-cig use began around 2005 and has risen dramatically since that time. By 2011, approximately 2% of all adult Americans used e-cigs, and 1 in 5 American smokers had tried vaping.”
High School Students: “According to the CDC’s National Youth Tobacco Survey, the percentage of high school students who reported using an e-cigarette even one time rose from 4.7% in 2011 to 10.0% in 2012.”

24. What we know Not yet regulated by FDA
Need more testing on long- term health effects
E-liquid or E-juice: Propylene glycol is GRAS, “generally recognized as safe” by the FDA, and used in inhalers, but no one knows the safety of long- term exposure via inhalation
Known toxins/carcinogens
Some contain tobacco-specific nitrosamines (TSNAs) and diethylene glycol (DEG)
Attractive industry advertising campaigns
“…flavors made in the USA with domestic and imported ingredients.”

25. What we Don’t know Do they have any harms?
How long will it take for evidence-based studies to conclude safety or harm?
Will e-cigs push back gains made on smoke-free environments?
Do e-cigs help smokers quit?
Are smokers “vaping” and continuing to smoke cigarettes?
Would it be fine/desirable for never-smokers to start “vaping”?
What is the impact on our our kids?

26. How to respond to patients questions about e-cigarettes FliPP
Figure out: “What interests you about e-cigarettes?”
Listen and Commend: “It sounds like you’re interested in quitting/cutting down/reducing harm from your tobacco use. That’s great! Stopping smoking is the best thing you can do for your health.”
Inform:
1) Dozens of companies make them
2) Not tested for safety—don’t know what they’re made of or what’s in the vapor
3) Don’t know if they help people stop smoking
Pivot: “For these reasons I can’t recommend e-cigarettes right now, BUT if it’s ok with you, I’ll describe some effective and safe options that are freely available for many patients…”
[e.g., nicotine inhaler, nasal spray, lozenge, gum, patch, other meds]
Plan: “Where would you like to go from here?”
[if patient doesn’t want to try to quit, or wants to try e-cigarettes, ask if you can check in with them later to see how they’re doing]

27. RECAP FLIPP Smokeless tobacco use leads to nicotine addiction
Smokeless tobacco use increases the risk of oral cancer, heart disease, and stroke
Most effective treatment for smokeless users is NRT and behavioral therapy
Dental health professionals can assess and refer patients for treatment
E-cigarettes have not been tested in the US for safety
FLIPP patients who want to use e-cigarettes to FDA-approved treatment options, if possible
FLIPP

28. Adam and provider can fill out together
QUIT Plan 5a’s
Adam and provider can fill out together
Support
Medications
Follow up in 2 weeks
Quit date is not necessary

29. Please take the quiz to complete the module
Click on the link below to take you to the quiz for this module
Thank you!
You may open the survey in your web browser by clicking the link below: Tobacco Module 4 Quiz If the link above does not work, try copying the link below into your web browser:
Babalola Faseru, MD, MPH
Department of Preventive Medicine and Public Health
University of Kansas Medical Center