1. RESTRICTING THE USE OF TOBACCO
CHAPTER 30

2. TOBACCO
Tobacco usage either smoked (cigarette and pipe) or chewed and or dipped, has become one of the larger health problems world wide to the degree that is considered by some a world epidemic
Consequences to tobacco usage include: a) expensive medical cost originated by prolonged treatments of diseases associated with tobacco usage b) increased demand on professional health services

3. SMOKELESS TOBACCO Smokeless tobacco is referred to as “spit tobacco”
Purpose is to make it sound less appealing to young population since it has the potential of increasing the prevalence of oral cancer in the future
There is no evidence that dry snuff causes caries and periodontal disease
Gingival recession at the site where dip is placed is common
STUDY: WOMEN SMOKERS VS DRY SNUFF Results: 4.6 chance of developing cancers of gingiva and buccal mucosa for smoker group and chance for smokeless tobacco users

4. PATHOLOGIC EFFECTS OF SMOKELESS TOBACCO
One form of smokeless tobacco is “snuff”, a powdered tobacco product which is used by placing a “dip” between the gingiva and cheek
Dry snuff contains N-nitrosamines ie: compounds implicated as carcinogens, especially for oral cancers
Continued use of snuff leads to localized tissue changes eg: leukoplakia
World Health Organization (WHO) defines leukoplakia as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease”

5. PATHOLOGIC EFFECTS OF SMOKELESS TOBACCO
If an oral white patch can be diagnosed as some other condition (eg: candidiasis, lichen planus, hyperkeratosis etc.) then the lesion should not be considered to be an example of leukoplakia
Leukoplakia is seen most frequently in middle-aged and older men, with an increasing prevalence with age
Less than 1% of men under the age of 30 have leukoplakia
Prevalence increases to 8% in men over the age of 70
Prevalence in women past the age of 70 is 2%
Common sites include: ________________________

6. LEUKOPLAKIA

7. EPIDEMIOLOGY
Oral cancer most commonly occurs in middle-aged and older individuals, although a number of these malignancies is also being documented in younger adults in recent years
Intraoral and oropharyngeal tumors are more common among men than women, with a male:female ratio of over 2:1

8. EPIDEMIOLOGY
The annual incidence of oral and pharyngeal cancer in African Americans (12.4 cases per 100,000 pop.) is higher than among whites (9.7 cases per 100,000)
The highest incidence rate is among African-American males (20.5 cases per 100,000 pop.)
Cancers of the lip vermillion occur primarily in white men
Lip tumors are mostly associated with chronic sun exposure, although sometimes related to the site where cigarettes have habitually been held

9. CANCER OF THE LIP

10. PREVALENCE OF SMOKELESS TOBACCO USE
Prevalence in Canada: % males over age 15 (chewing tobacco) 0.4% males over age 15 (dry snuff)
Prevalence is widespread among professional baseball players
Usage of smokeless tobacco is highest in the South, in rural areas, and declines with increasing education

11. PREVENTION
Prevention against the diseases that come with smokeless tobacco is based on the public and individual education to eliminate the habit or not to begin in the first place
Comprehensive Smokeless Tobacco Health Education Act includes the following:
develop and implement health education programs / materials to inform public of health risks
prohibit radio and television advertising
authorize research on effects of smokeless tobacco
disclose the ingredients used in producing smokeless tobacco ie: amount of nicotine used

12. PREVENTION
Many smokeless tobacco users report using it in conjunction with alcohol, cigarettes, and marijuana
Peer pressure is a strong influence in getting started
Programs of media advertising and school health education programs are implemented to discourage the initiation of smokeless tobacco use
These programs are monitored by surveys

13. HELPING CLIENTS KICK THE TOBACCO HABIT
Knowing why a client uses tobacco helps to identify what method will help them quit. Some of the reasons are:
Peer pressure
Social pressure and Association
Behavior
Nicotine Addiction
Salt Cravings

14. CESSATION TECHNIQUES EDUCATION Educate clients on dangers of tobacco
Give your clients literature from the American Cancer Society and National Cancer Institute
Give your clients posters, pamphlets and repeated reminders (ie: intervention) to not start using tobacco can be very influential
QUITTING COLD TURKEY
Encourage quitting and give support to clients whenever possible
Chewers who have not been chewing very long are often successful with this method

15. CESSATION TECHNIQUES CHEWING AN ALTERNATIVE
Mint Snuff products allow individuals to yield to the cravings of the behavior without the danger of tobacco
TITRATION
Some chewers who have strong nicotine withdrawl find it helpful to mix Mint Snuff with their tobacco
ALTERNATING DIPS
Use tobacco and Mint Snuff alternately starting every other dip then gradually using Mint Snuff more

16. CESSATION TECHNIQUES USE OF NICOTINE PATCHES
Recommended for those chewers who display definite signs of nicotine withdrawal
USE OF NICOTINE GUM (NICORETTE)
Studies have suggested that nicotine gum has not been very helpful in cessation efforts
PRESCRIPTION OF WELLBUTRIN (ZYBAN)
Some baseball players quit using this method
Anti-depressant pill

17. INTERVENTION TECHNIQUES
One of the most difficult things to deal with when intervening with a patient about tobacco use is
HOW AND WHEN TO DO IT
Just telling a patient that they should quit chewing and not offering any assistance or alternatives could create stress for the patient
By offering an alternative, you can establish a good relationship and give the patient something to use in their own quitting process
When combined into a comprehensive intervention plan, the overall effect towards ultimate cessation can be quite effective

18. INTERVENTION TECHNIQUES
As a dental professional, it is important to be consistent ie: ask every patient on each visit if they use tobacco
If they don’t, praise them for non-use and urge them to continue avoiding tobacco
If they do chew, inform them of the dangers of tobacco, provide them literature and ask them if they want to quit
Tell them “When you want to quit, let me know and I can help” and then carry on with routine dental procedures
Don’t badger, just let them know that you care and you can help
Cessation experts report that unless a person is ready to quit, your chances of helping them is very low