TOBACCO
MODULE 4
Smokeless
Tobacco
Dental
Health
Intervention
Electronic
Cigarettes
KAMU
Kansas Association for
the Medically
Underserved
GOALS: TOBACCO CESSATION TRAINING
COMMUNIT Y HEALTH CLINICS
 Module 1: Why is it Hard to Quit?
 Module 2: Ask, Advise, Assist, Refer
 Module 3: Quit Smoking Medications
Babalola Faseru, MD, MPH
Department of Preventive
Medicine and Public Health
University of Kansas
Medical Center
 Module 4: Smokeless Tobacco, Dental Health
Intervention and E-cigarettes
 Module 5: Office Systems and Creating a Quit Plan
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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
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SMOKELESS TOBACCO
Babalola Faseru, MD, MPH
Department of Preventive
Medicine and Public Health
University of Kansas
Medical Center
HARMFUL & HIGHLY ADDICTIVE
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T YPES 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
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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
Leukoplakia
Addiction
• Use leads to nicotine addiction and dependence
http://www.ctri.wisc.edu/HC.Providers/spit/Spit_tobacco_treatment.pdf
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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.”
HTTP://WWW.NIDCR.NIH.GOV/ORALHEALTH/TOPICS/SMOKELESSTOBACCO/SMOKELES STOBA
CCOAGUIDEFORQUITTING.HTM
Two
main types of
smokeless
tobacco
in the U.S.
1. Chewing
Tobacco
2. Snuf f
Snus by Andreas
Hagerman
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SMOKELESS TOBACCO USE IN KANSAS
2010-2011
Gender differences
Ethnic differences (high school)
Adult:
 African Americans 10.5%
 Males:
 Dual use: 13.3%
 Exclusively: 5.3%
 Caucasian 9.3%
 Females: <1%
 Other race 7.0%
High school students:
Male: 15.5%; Females: < 2%
Middle school students:
Males: 4.1%; Females: <2%
Kansas Tobacco Youth Survey, 2010; http://www.kdheks.gov/tobacco/download/YTS2010_FactSheet.pdf
Kansas BRFSS Tobacco and Adult Report, 2011; http://www.kdheks.gov/brfss/PDF/2011_BRFSS_Kansas_Tobacco.pdf
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TOBACCO COMPANY MARKETING
TO YOUTH
Chewing Tobacco Candy by Zombieite
http://goo.gl/Gp9glg
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ST TREATMENT STRATEGY IS DIFFERENT
Smokeless Dependence
Tobacco Dependence
 Normal dip or chew
contains 3.6 to 4.5 mg
nicotine
 Cigarette contains 1.8 mg
nicotine
 Nicotine in dip or chew
takes 30 minutes for the
nicotine to be absorbed
into system
 Nicotine from cigarette
drag takes 7 seconds to
reach brain and
dopamine release
 With ST, nicotine
continues to be absorbed
60 minutes after the
tobacco is removed
 Once cigarette is
extinguished, individual is
no longer receiving
nicotine
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 Encourage
counseling
EVIDENCE-BASED TREATMENT FOR ADULTS
COMBINATION OF BEHAVIORAL TREATMENT AND
NRT IS MOST EFFECTIVE
 Identify
triggers
 Modify
behaviors
that
increase
risk for
relapse
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
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NICOTINE LOZENGE OR GUM
TO C ON TROL C R AV I NG S A N D W I TH D R AWA L SY M PTOMS
Gum
Lozenge
If the first dip < 30 minutes of awakening,
or patient is using >3 cans or pouches of
tobacco per week:
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:
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.
Limit to 10-12 pieces of gum per day. Taper as
needed to control cravings and withdrawal
symptoms.
Prescribe 4 mg Nicotine gum (1-2
pieces) every 1-2 hours as needed
Prescribe 2 mg Nicotine gum (1-2
pieces) every 1-2 hours as needed
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
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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:
http://quitgroups.com/2013/10/03/otc-nicotine-replacement-therapies
/
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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.
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DENTAL HEALTH INTERVENTION
WHY SHOULD DENTAL PRACTICES INTERVENE?
Leukoplakia
(oral precancer)
on floor of
mouth and
tongue
http://www.who.int/oral_health/
publications/fact_sheet_tobacco
/en/index1.html
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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
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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?
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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 .”
A m e r i c a n D e n t a l H y g i e n i s t s A s s o c i a t i o n ; h t t p : / / w w w . a s k a d v i s e r e f e r. o r g /
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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…
 Ask about tobacco use
 Advise to quit
1. Medical clinic provider
for medication
2. KS Quitline
 Assist with medication
 Refer to KS Quitline
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E-CIGARETTES
what’s
the
buzz?
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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
Howstuffworks.com
nicotine, H 2 0, anything else
manufacture wants to put in or
fails to clean out
 “Vaping”
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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 .”
http://www.ctri.wisc.edu/HC.Providers/healthcare_ecigs.htm
http://managedhealthcareexecutive.modernmedicine.com/managed -healthcare-executive/news/cdcseeks-answers-e-cigarette-use-among-kids#sthash.zuhVJUNW.dpuf
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WHAT WE KNOW
 Not yet regulated by FDA
 Need more testing on long term health ef fects
 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 tobaccospecific nitrosamines (TSNAs)
and diethylene glycol (DEG)
 Attractive industry
advertising campaigns
 “…flavors made in the USA
with domestic and imported
ingredients.”
http://www.blucigs.com/
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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 smokefree 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?
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm?s_cid=mm6235a6_w
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HOW TO RESPOND TO PATIENTS
QUESTIONS ABOUT E -CIG ARETTES
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]
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm173401.htm
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RECAP
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
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Tobacco Quit Plan
For: ________________________________________
SUPPORT:
DOB: __ __ /__ __ /__ __ __ __
Ongoing support/counseling double chances of quitting
QUIT PLAN
5A’S
☐ KanQuit - the Free Kansas Tobacco Quitline (1-800-QUIT NOW)
☐ Referred on: __ __ /__ __ /__ __ by (initials) ___ ___ ___
☐ This clinic
☐ Another source – (describe): ________________________________________
MEDICATION: Quit tobacco medications double/triple chances of quitting
Nicotine Replacement:
☐ patch _____mg
Non-nicotine medication:
☐ bupropion: __________________
☐ gum or lozenge _____mg
☐ varenicline (Chantix)
☐ inhaler ______mg
☐ other:_______________________
☐ nasal spray ______mg
☐none:________________________
I will get my medication from the following source: ______________________
_____________________________________________________________
FOLLOW UP/RECYCLE Quitting tobacco is a process
1. Date: __ __ /__ __ /__ __ Status: ☐Actively quitting
☐Quit
☐Relapsed ☐Other: _____________
Adam and
provider can fill
out together
 Suppor t
 Medications
 Follow up in 2
weeks
 Quit date is
not necessar y
Next steps: Support: _________________________ Medications: __________________________
Notes: ____________________________________________________________________________
2. Date: __ __ /__ __ /__ __ Status: ☐Actively quitting
☐Quit
☐Relapsed ☐Other: _____________
Next steps: Support: _________________________ Medications: __________________________
Notes: ___________________________________________________________________________
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PLEASE TAKE THE QUIZ TO COMPLETE THE MODULE
Click on the link below to take you to the quiz for this module
Babalola Faseru, MD, MPH
Department of Preventive
Medicine and Public Health
University of Kansas
Medical Center
Thank you!
Yo u m ay o pe n t h e s ur vey i n yo ur we b brow s e r by c l i c king t h e l i nk be l ow :
Tobacco Module 4 Quiz
I f t h e l i n k a b o v e d o e s n o t w o r k , t r y c o py in g t h e l i n k b e l o w i n to yo u r w e b b r o w s e r :
h t t p s :/ / r e d ca p . kum c. e d u/ s ur v ey s / ? s = U i k j cv
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