Dr. Ebbert Spit Tobacco Presentation

Mayo Clinic College of Medicine. All Rights Reserved.

What You Need to Know aboutWhat You Need to Know aboutSmokeless TobaccoSmokeless Tobacco

What You Need to Know aboutWhat You Need to Know aboutSmokeless TobaccoSmokeless Tobacco

Jon O. Ebbert, MD, MScJon O. Ebbert, MD, MSc

Assistant Professor of MedicineAssistant Professor of Medicine

Mayo Clinic College of Medicine Mayo Clinic College of Medicine

Rochester, MNRochester, MN

Jon O. Ebbert, MD, MScJon O. Ebbert, MD, MSc

Assistant Professor of MedicineAssistant Professor of Medicine

Mayo Clinic College of Medicine Mayo Clinic College of Medicine

Rochester, MNRochester, MN


Goals & ObjectivesGoals & ObjectivesGoals & ObjectivesGoals & Objectives

• Understand the productsUnderstand the products

• Prevalence of usePrevalence of use

• Health effectsHealth effects

• Neurobiology of smokeless tobacco useNeurobiology of smokeless tobacco use

• Marketing messagesMarketing messages

• Current treatmentCurrent treatment








Smokeless Tobacco: Definitions

• Chewing tobaccoChewing tobacco– Loose leaf (i.e., Redman)Loose leaf (i.e., Redman)– PlugsPlugs– TwistsTwists

• SnuffSnuff– Moist (Copenhagen, Skoal)Moist (Copenhagen, Skoal)– Dry (Honest, Honey bee, Navy, Square)Dry (Honest, Honey bee, Navy, Square)


Chewing TobaccoChewing Tobacco


SnuffSnuff


Type of ST Used in U.S.Type of ST Used in U.S.Type of ST Used in U.S.Type of ST Used in U.S.

National Survey on Drug Use and Health, 2003

Chewing Tobacco SnuffChewing Tobacco Snuff


Preferred Snuff ProductsPreferred Snuff ProductsPreferred Snuff ProductsPreferred Snuff Products



Preferred Chewing TobaccoPreferred Chewing TobaccoPreferred Chewing TobaccoPreferred Chewing Tobacco



RJ Reynold’s


Phillip Morris (Altria)Phillip Morris (Altria)


Other ST ProductsOther ST Products

USSTC

Swedish Match, NA

BAT


Scandinavian Snus


Results from the 2006 National Survey on Drug Use and Health: National Findings

Past Month Tobacco Use among Persons Aged 12 or Older: 2002-2006


PrevalencePrevalence

• ST use is higher in rural areas than in urban areas

• Rural counties 8.0%

• Large metropolitan areas 1.7%

• Differs by geographic area

• South 4.1% (highest)

• NE 1.5% (lowest)

• Lower among college graduates (2.2%) vs. high school completer/non-completers with no college (3.7%)

• ST use is higher in rural areas than in urban areas

• Rural counties 8.0%

• Large metropolitan areas 1.7%

• Differs by geographic area

• South 4.1% (highest)

• NE 1.5% (lowest)

• Lower among college graduates (2.2%) vs. high school completer/non-completers with no college (3.7%)

2004 National Survey on Drug Use and Health


Health Impact of Smokeless TobaccoHealth Impact of Smokeless Tobacco


ST - Health Consequences ST - Health Consequences ST - Health Consequences ST - Health Consequences

Report on Carcinogens, 10th Edition, National Report on Carcinogens, 10th Edition, National Toxicology Program, USDHHSToxicology Program, USDHHS

Smokeless tobaccoSmokeless tobacco

““Known to be a human carcinogen”Known to be a human carcinogen”

Report on Carcinogens, 10th Edition, National Report on Carcinogens, 10th Edition, National Toxicology Program, USDHHSToxicology Program, USDHHS

Smokeless tobaccoSmokeless tobacco

““Known to be a human carcinogen”Known to be a human carcinogen”


Health Effects: Cancers - U.S. Data

Health Effects: Cancers - U.S. Data

Location OR (95% CI)

Cancer, Mouth and Gum 11.2 (4.1-30.7)A

Gum & Buccal Mucosa 4.2 (2.6-6.7)B

Larynx 7.3 (2.9-18.3)A

Salivary gland 5.3 (1.2-23.4)A

Kidney 4.0 (1.2-12.9)C

Pancreatic 3.6 ( 1.0-12.8)D

Location OR (95% CI)

Cancer, Mouth and Gum 11.2 (4.1-30.7)A

Gum & Buccal Mucosa 4.2 (2.6-6.7)B

Larynx 7.3 (2.9-18.3)A

Salivary gland 5.3 (1.2-23.4)A

Kidney 4.0 (1.2-12.9)C

Pancreatic 3.6 ( 1.0-12.8)D

A - Stockwell HG, et al. Head Neck Surg. 1986 Nov-Dec;9(2):104-10. B - Winn DM, et al. N Engl J Med. 1981 Mar 26;304(13):745-9. C - Goodman MT, et al. Am J Epidemiol. 1986 Dec;124(6):926-41. D - Muscat JE, et al. Cancer Epidemiol Biomarkers Prev. 1997 Jan; 6(1):15-9.


ST Health Effects: CV DiseaseST Health Effects: CV Disease

• CPS-II

• *Current ST use vs. never associated with death from:

• All causes: HR 1.18 (95% CI: 1.08-1.29)• CHD: HR 1.26 (95% CI: 1.08-1.47)• Cerebrovascular dz: HR 1.40 (95% CI: 1.10-1.79)

• No difference between snuff and chewing tobacco• Former use did increase the risk of death in any category

• CPS-II

• *Current ST use vs. never associated with death from:

• All causes: HR 1.18 (95% CI: 1.08-1.29)• CHD: HR 1.26 (95% CI: 1.08-1.47)• Cerebrovascular dz: HR 1.40 (95% CI: 1.10-1.79)

• No difference between snuff and chewing tobacco• Former use did increase the risk of death in any category

Henley et al., Canc Cause Control. 2005; 16: 347-358.*Multivariate-adjusted


ST - Oral LesionsST - Oral LesionsST - Oral LesionsST - Oral Lesions

• LeukoplakiaLeukoplakia

• Oral cancerOral cancer

• Dental diseaseDental disease• erosion of enamelerosion of enamel• dental cariesdental caries

• Periodontal DiseasePeriodontal Disease• gingival recessiongingival recession• soft tissue/hard tissue losssoft tissue/hard tissue loss• gingivitisgingivitis

• LeukoplakiaLeukoplakia

• Oral cancerOral cancer

• Dental diseaseDental disease• erosion of enamelerosion of enamel• dental cariesdental caries

• Periodontal DiseasePeriodontal Disease• gingival recessiongingival recession• soft tissue/hard tissue losssoft tissue/hard tissue loss• gingivitisgingivitis


Tobacco-Related Oral DiseaseTobacco-Related Oral DiseaseTobacco-Related Oral DiseaseTobacco-Related Oral Disease


Smokeless Tobacco DependenceSmokeless Tobacco Dependence


Volkow et al. J. Pharmacol. Exp. Ther. 291:409-415, 1999

The intensity of the "high" induced by methylphenidate is significantly correlated with the levels of released dopamine (r = 0.78, p <.001)..

““High” Intensity & Dopamine ReleaseHigh” Intensity & Dopamine Release


Smokeless Tobacco PharmacologySmokeless Tobacco PharmacologySmokeless Tobacco PharmacologySmokeless Tobacco Pharmacology

Blo

od

nic

oti n

e c

on

cen

t ra

ti on

(ng

/ml)

Benowitz, NL et al. Nicotine absorption and cardiovascular effects with smokeless tobacco use: comparison with cigarettes and nicotine gum. Clin Pharmacol Ther 1988; 44: 23-8.

Benowitz NL, et al. Clin Pharmacol Ther. 1988 Jul;44(1):23-8. Figure Used with Permission from Elsevier.


ST Characteristics Affecting Nicotine Blood LevelsST Characteristics Affecting Nicotine Blood LevelsST Characteristics Affecting Nicotine Blood LevelsST Characteristics Affecting Nicotine Blood Levels

• Concentration of nicotine in ST productConcentration of nicotine in ST product

• Size of the tobacco cuttingsSize of the tobacco cuttings• Long cutLong cut• Fine cut (higher)Fine cut (higher)

• Ammonium bicarbonate (additive)Ammonium bicarbonate (additive)• Lower acid level of product = higher free nicotineLower acid level of product = higher free nicotine

• Acetic acid (additive)Acetic acid (additive)• Increases salivation – enhances absorptionIncreases salivation – enhances absorption

• Concentration of nicotine in ST productConcentration of nicotine in ST product

• Size of the tobacco cuttingsSize of the tobacco cuttings• Long cutLong cut• Fine cut (higher)Fine cut (higher)

• Ammonium bicarbonate (additive)Ammonium bicarbonate (additive)• Lower acid level of product = higher free nicotineLower acid level of product = higher free nicotine

• Acetic acid (additive)Acetic acid (additive)• Increases salivation – enhances absorptionIncreases salivation – enhances absorption

Richter P, et al. Nicotine Tob Res. 2003 Dec;5(6):885-9.


CDC, 1999.

Free Nicotine as a Function of pH


Impact of pH ManipulationImpact of pH Manipulation

• Likelihood of choosing a brand with higher nicotine content is related to:

• Increasing duration of use• Increasing intensity of use• Frequency of ST use [Tomar, 1995 #2892]

• ST users who have used higher nicotine-containing products are more likely to report:

• More nicotine withdrawal symptoms• Continued use because of difficulty quitting

• Likelihood of choosing a brand with higher nicotine content is related to:

• Increasing duration of use• Increasing intensity of use• Frequency of ST use [Tomar, 1995 #2892]

• ST users who have used higher nicotine-containing products are more likely to report:

• More nicotine withdrawal symptoms• Continued use because of difficulty quitting

Tomar, SL, et al. Tob Control 4: 67-72.


Frequency of Withdrawal Symptoms in 162 ST UsersFrequency of Withdrawal Symptoms in 162 ST UsersFrequency of Withdrawal Symptoms in 162 ST UsersFrequency of Withdrawal Symptoms in 162 ST Users

0%

10%

20%

30%

40%

50%

60%

70%

CravingIrritabilityIncreased eatingAnxietyImpatienceRestlessnessDepressed moodDifficulty concentratingDisrupted sleep

0%

10%

20%

30%

40%

50%

60%

70%

CravingIrritabilityIncreased eatingAnxietyImpatienceRestlessnessDepressed moodDifficulty concentratingDisrupted sleep

Ebbert JO, et al. Journal of Substance Abuse Treatment, 26(4), 261-267.


MarketingMessagesMarketingMessages

http://www.trinketsandtrash.org


Cowboy/RodeoCowboy/Rodeo



Active LifestyleActive Lifestyle



“Social” Lifestyle“Social” Lifestyle



Individuality

“Not everybody understands it. Which is exactly why you do it.”



Brave New World – What’s a Smoker To Do?

Brave New World – What’s a Smoker To Do?



Brave New World – What’s a Smoker

To Do?

Brave New World – What’s a Smoker

To Do?



Appeals to Females?Appeals to Females?



Methods of Treating Smokeless Methods of Treating Smokeless Tobacco UseTobacco Use


Behavioral

Pharmacologic


AssistAssist

1. Set a quit date

2. Remove all tobacco products & memorabilia

3. Tell friends/family if and only if user is willing

3. Provide behavioral & pharmacologic support


Behavioral InterventionsBehavioral InterventionsBehavioral InterventionsBehavioral Interventions

• Oral health feedback

• Advice to quit

• Materials

• + Set quit date & videos

Severson HH et al. (1998). Journal of the American Dental Association, 129(7), 993-999.

• Oral health feedback

• Presentation from coach

• Team support


If User Wants to Use Gradual ReductionIf User Wants to Use Gradual Reduction

• Brand switching• Copenhagen to Skoal

• Nicotine fading• Reduce by 1-2 dips/day• Quit at 50% of baseline

• Blending• Snuff substitute mix• 1/3 for 2 weeks, 2/3 for two weeks• 100% snuff substitute

• Brand switching• Copenhagen to Skoal

• Nicotine fading• Reduce by 1-2 dips/day• Quit at 50% of baseline

• Blending• Snuff substitute mix• 1/3 for 2 weeks, 2/3 for two weeks• 100% snuff substitute

Severson HH et al. (1999). Primary Care; Clinics in Office Practice, 26(3), 529-551.Severson HH et al. (1999). Primary Care; Clinics in Office Practice, 26(3), 529-551.


Snuff SubstitutesSnuff SubstitutesSnuff SubstitutesSnuff Substitutes

• Smokey Mountain®Smokey Mountain®

• Golden Eagle®Golden Eagle®

• Oregon Mint®Oregon Mint®

• KIK IT®KIK IT®

• Jerky®Jerky®

• Bacc-Off®Bacc-Off®

• Smokey Mountain®Smokey Mountain®

• Golden Eagle®Golden Eagle®

• Oregon Mint®Oregon Mint®

• KIK IT®KIK IT®

• Jerky®Jerky®

• Bacc-Off®Bacc-Off®


Additional ToolsAdditional Tools

• Gum

• Hard candy

• Raisins

• Cinnamon sticks

• Toothpicks

• Gum

• Hard candy

• Raisins

• Cinnamon sticks

• Toothpicks




Behavioral

Pharmacologic


EMPHASIZE!!!!EMPHASIZE!!!!

• Nicotine is not what we fear – tobacco is the culprit

• Nicotine does not cause:• Cancer• Heart disease

• Communicate: “Smokeless tobacco is a nicotine delivery device and we are trying to prevent the side effects of this device”

• Oral disease• Cancer

• Nicotine is not what we fear – tobacco is the culprit

• Nicotine does not cause:• Cancer• Heart disease

• Communicate: “Smokeless tobacco is a nicotine delivery device and we are trying to prevent the side effects of this device”

• Oral disease• Cancer


Recommended ST Treatment ApproachRecommended ST Treatment ApproachRecommended ST Treatment ApproachRecommended ST Treatment Approach

1) Behavioral treatment1) Behavioral treatment• Oral examinationOral examination• +/- oral replacement products+/- oral replacement products

2) Bupropion2) Bupropion• 150 mg po qd x 3 days then bid150 mg po qd x 3 days then bid• Quit 1 week laterQuit 1 week later• Continue for 3-6 monthsContinue for 3-6 months

3) Tailored nicotine patch therapy3) Tailored nicotine patch therapy• +/- gum/lozenge for self-titration+/- gum/lozenge for self-titration

1) Behavioral treatment1) Behavioral treatment• Oral examinationOral examination• +/- oral replacement products+/- oral replacement products

2) Bupropion2) Bupropion• 150 mg po qd x 3 days then bid150 mg po qd x 3 days then bid• Quit 1 week laterQuit 1 week later• Continue for 3-6 monthsContinue for 3-6 months

3) Tailored nicotine patch therapy3) Tailored nicotine patch therapy• +/- gum/lozenge for self-titration+/- gum/lozenge for self-titration


Nicotine LozengeNicotine Lozenge

• Nicotine Polacrilex•2 mg•4 mg

• Dissolves in mouth over 20-30 minutes

• Delivers 25% more nicotine than the gum

• Nicotine Polacrilex•2 mg•4 mg

• Dissolves in mouth over 20-30 minutes

• Delivers 25% more nicotine than the gum


Proper Lozenge PlacementProper Lozenge Placement

4 NL


Goals & ObjectivesGoals & ObjectivesGoals & ObjectivesGoals & Objectives













Dr. Ebbert Spit Tobacco Presentation

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