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Tobacco Module 4 Smokeless Tobacco Dental Health Intervention

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Presentation on theme: "Tobacco Module 4 Smokeless Tobacco Dental Health Intervention"— Presentation transcript:

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: https://redcap.kumc.edu/surveys/?s=Uikjcv Babalola Faseru, MD, MPH Department of Preventive Medicine and Public Health University of Kansas Medical Center


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