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

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Presentation on theme: "Smokeless Tobacco Dental Health Intervention Electronic Cigarettes KAMU Kansas Association for the Medically Underserved TOBACCO MODULE 4."— Presentation transcript:

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2 Smokeless Tobacco Dental Health Intervention Electronic Cigarettes KAMU Kansas Association for the Medically Underserved TOBACCO MODULE 4

3 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 2 GOALS: TOBACCO CESSATION TRAINING COMMUNITY HEALTH CLINICS Babalola Faseru, MD, MPH Department of Preventive Medicine and Public Health University of Kansas Medical Center

4 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 dont know What do you tell your patients 3 OBJECTIVES

5 4 SMOKELESS TOBACCO HARMFUL & HIGHLY ADDICTIVE Babalola Faseru, MD, MPH Department of Preventive Medicine and Public Health University of Kansas Medical Center

6 Snus (snoose)Scandinavian moist powder tobacco product (place under upper lipless need to spit) SnusAmerican 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 5 TYPES OF SMOKELESS TOBACCO

7 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

8 Two main types of smokeless tobacco in the U.S. 1.Chewing Tobacco 2.Snuff 7 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. CCOAGUIDEFORQUITTING.HTM Snus by Andreas Hagerman

9 Gender differences 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% Ethnic differences (high school) African Americans 10.5% Caucasian 9.3% Other race 7.0% 8 SMOKELESS TOBACCO USE IN KANSAS Kansas Tobacco Youth Survey, 2010; Kansas BRFSS Tobacco and Adult Report, 2011;

10 Chewing Tobacco Candy by Zombieite 9 TOBACCO COMPANY MARKETING TO YOUTH

11 Tobacco Dependence 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 Smokeless 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 10 ST TREATMENT STRATEGY IS DIFFERENT

12 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

13 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

14 Lozenge If the first dip 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. Gum If the first dip 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. 13 NICOTINE LOZENGE OR GUM 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

15 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. 14 COMBINATION NRT THERAPY Nicotine gum photo: /

16 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. 15 OTHER MEDICATIONS

17 Leukoplakia (oral precancer) on floor of mouth and tongue publications/fact_sheet_tobacco /en/index1.html 16 DENTAL HEALTH INTERVENTION WHY SHOULD DENTAL PRACTICES INTERVENE?

18 Tobacco - major risk factor oral cancers periodontal disease, bone and attachment loss Cigarette smoking slows healing during periodontal treatment significantly associated with implant failure 17 CIGARETTES AND SMOKELESS HARM DENTAL HEALTH

19 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 Adams girlfriend complains of his bad breath He likes to use a new snus pouch every 3 hours Note: Adams dad used moist snuff for 30 years How can you address Adams tobacco addiction? 18 ADAM COMES TO THE DENTAL CLINIC

20 ASK: I see from your health history that you use tobacco. Id 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: Id 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; 19 DENTAL HEALTH PROFESSIONAL ASK, ADVISE, REFER MODEL

21 Dental Clinic (AAR) Ask about tobacco use Advise to quit Assist with medication Refer to KS Quitline Medical Clinic (AAAR) Ask about tobacco use Advise to quit Refer to… 1.Medical clinic provider for medication 2.KS Quitline 20 DENTAL AND MEDICAL CLINICS CAN WORK TOGETHER TO HELP TOBACCO USERS QUIT

22 21 E-CIGARETTES whats the buzz?

23 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, H 2 0, anything else manufacture wants to put in or fails to clean out Vaping 22 ELECTRONIC CIGARETTES Howstuffworks.com

24 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 CDCs 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 seeks-answers-e-cigarette-use-among-kids#sthash.zuhVJUNW.dpuf 23 E-CIGARETTE USE

25 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 WHAT WE KNOW

26 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? 25 WHAT WE DONT KNOW

27 Figure out: What interests you about e-cigarettes? Listen and Commend: It sounds like youre interested in quitting/cutting down/reducing harm from your tobacco use. Thats great! Stopping smoking is the best thing you can do for your health. Inform: 1) Dozens of companies make them 2) Not tested for safetydont know what theyre made of or whats in the vapor 3) Dont know if they help people stop smoking Pivot: For these reasons I cant recommend e-cigarettes right now, BUT if its ok with you, Ill 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 doesnt want to try to quit, or wants to try e-cigarettes, ask if you can check in with them later to see how theyre doing] 26 HOW TO RESPOND TO PATIENTS QUESTIONS ABOUT E-CIGARETTES FLIPP

28 27 RECAP

29 Adam and provider can fill out together Support Medications Follow up in 2 weeks Quit date is not necessary 28 QUIT PLAN 5AS

30 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 Tobacco Module 4 Quiz https://redcap.kumc.edu/surveys/?s=Uikjcv 29 PLEASE TAKE THE QUIZ TO COMPLETE THE MODULE Babalola Faseru, MD, MPH Department of Preventive Medicine and Public Health University of Kansas Medical Center


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