Presentation on theme: "Tobacco Module 4 Smokeless Tobacco Dental Health Intervention"— Presentation transcript:
1Tobacco Module 4 Smokeless Tobacco Dental Health Intervention Electronic CigarettesKAMUKansas Association for the Medically Underserved
2Goals: Tobacco Cessation Training Community Health Clinics Module 1: Why is it Hard to Quit?Module 2: Ask, Advise, Assist, ReferModule 3: Quit Smoking MedicationsModule 4: Smokeless Tobacco, Dental Health Intervention and E-cigarettesModule 5: Office Systems and Creating a Quit PlanBabalola Faseru, MD, MPHDepartment of Preventive Medicine and Public HealthUniversity of Kansas Medical Center
3Types of Smokeless Tobacco ObjectivesTypes of Smokeless TobaccoPrevalence, Health Effects, and How to Treat“Ask, Advise, Refer” Model for Dental PracticeE-cigarettesWhat we knowWhat we don’t knowWhat do you tell your patients
4Smokeless Tobacco Harmful & Highly Addictive Babalola Faseru, MD, MPHDepartment of Preventive Medicine and Public HealthUniversity of Kansas Medical CenterSmokeless Tobacco Harmful & Highly Addictive
5Types of smokeless tobacco Snus (snoose)—Scandinavianmoist powder tobacco product (place under upper lip—less need to spit)Snus—Americansimilar to Scandinavian but no regulationDipping tobaccomoist snuff (lower lip and gums) causes excess saliva, could require spittingNasal SnuffFinely ground dry form of tobacco “snuffed” through the noseChewing tobaccolong strands placed between cheeks, gum, or teeth (plugs, wads, chew)Dissolvablesstrips, sticks, orbs and compressed tobacco lozenges
6HEALTH EFFECTS OF Smokeless tobacco Cancer RiskSmokeless tobacco contains 28 carcinogensIncreases the risk of developing several cancersOral Health DangersIncreases the risk of developing precancerous mouth lesionsStrongly associated with recession of the gums.Heart Disease and StrokeStrongly associated with heart disease and strokeAddictionUse leads to nicotine addiction and dependenceLeukoplakia
7Snus 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.”Twomain types ofsmokeless tobaccoin the U.S.Chewing TobaccoSnuffSnus by Andreas Hagerman
8Smokeless tobacco USE in Kansas 2010-2011 Gender differencesEthnic 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;
9Tobacco Company Marketing to youth Chewing Tobacco Candy by Zombieite
10ST treatment Strategy is different Smokeless DependenceTobacco DependenceNormal dip or chew contains 3.6 to 4.5 mg nicotineNicotine in dip or chew takes 30 minutes for the nicotine to be absorbed into systemWith ST, nicotine continues to be absorbed 60 minutes after the tobacco is removedCigarette contains 1.8 mg nicotineNicotine from cigarette drag takes 7 seconds to reach brain and dopamine releaseOnce cigarette is extinguished, individual is no longer receiving nicotine
11Encourage counselingIdentify triggersModify behaviors that increase risk for relapseEvidence-based treatment for adults Combination of behavioral treatment and NRT is most effective
12Evidenced-based Treatment for Adults Nicotine Replacement Therapy (NRT)The dose is based on amount of Smokeless Tobacco used/week:The Nicotine PatchIf > 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
13Nicotine 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 neededIf 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 neededLimit 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 neededIf 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 neededLimit 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
14Combination 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:
15Other medicationsProven 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.
16Dental Health Intervention WHY SHOULD DENTAL PRACTICES INTERVENE? Leukoplakia (oral precancer) on floor of mouth and tongueDental Health Intervention WHY SHOULD DENTAL PRACTICES INTERVENE?
17Cigarettes and Smokeless harm dental health Tobacco - major risk factororal cancersperiodontal disease, bone and attachment lossCigarette smoking slows healingduring periodontal treatmentsignificantly associated with implant failure
18Adam comes to the Dental Clinic He is 24He has never seen a dental hygienistHis workplace is smoke-freeAdam likes to use snus because no one can see it and he doesn't need to spitAdam’s girlfriend complains of his bad breathHe likes to use a new snus pouch every 3 hoursNote: Adam’s dad used moist snuff for 30 yearsHow can you address Adam’s tobacco addiction?
19Dental 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;
20Dental and medical clinics Can work together to help tobacco users quit Dental Clinic (AAR)Medical Clinic (AAAR)Ask about tobacco useAdvise to quitRefer to…Medical clinic provider for medicationKS QuitlineAsk about tobacco useAdvise to quitAssist with medicationRefer to KS Quitline
22Electronic cigarettes Hand-held devices that mimic the act of smokingDo not contain tobaccoBattery heats device and makes the tip glowThe user inhales vapornicotine, H20, anything else manufacture wants to put in or fails to clean out“Vaping”Howstuffworks.com
23E-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.”
24What we know Not yet regulated by FDA Need more testing on long- term health effectsE-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 inhalationKnown toxins/carcinogensSome contain tobacco-specific nitrosamines (TSNAs) and diethylene glycol (DEG)Attractive industry advertising campaigns“…flavors made in the USA with domestic and imported ingredients.”
25What 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?
26How 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 them2) Not tested for safety—don’t know what they’re made of or what’s in the vapor3) Don’t know if they help people stop smokingPivot: “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]
27RECAP FLIPP Smokeless tobacco use leads to nicotine addiction Smokeless tobacco use increases the risk of oral cancer, heart disease, and strokeMost effective treatment for smokeless users is NRT and behavioral therapyDental health professionals can assess and refer patients for treatmentE-cigarettes have not been tested in the US for safetyFLIPP patients who want to use e-cigarettes to FDA-approved treatment options, if possibleFLIPP
28Adam and provider can fill out together QUIT Plan 5a’sAdam and provider can fill out togetherSupportMedicationsFollow up in 2 weeksQuit date is not necessary
29Please take the quiz to complete the module Click on the link below to take you to the quiz for this moduleThank 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=UikjcvBabalola Faseru, MD, MPHDepartment of Preventive Medicine and Public HealthUniversity of Kansas Medical Center