© 2003 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Smokeless (Spit)...

Smokeless (Spit) Tobacco Use: Smokeless (Spit) Tobacco Use:

Comprehensive Treatment ModelComprehensive Treatment Model

Smokeless (Spit) Tobacco Use: Smokeless (Spit) Tobacco Use:

Comprehensive Treatment ModelComprehensive Treatment Model

Lowell C. Dale, MDLowell C. Dale, MD

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

Assistant Professors of Medicine Assistant Professors of Medicine

Mayo Clinic College of MedicineMayo Clinic College of Medicine

Nicotine Dependence CenterNicotine Dependence Center

Lowell C. Dale, MDLowell C. Dale, MD

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

Assistant Professors of Medicine Assistant Professors of Medicine

Mayo Clinic College of MedicineMayo Clinic College of Medicine

Nicotine Dependence CenterNicotine Dependence Center

Goals & ObjectivesGoals & ObjectivesGoals & ObjectivesGoals & Objectives

• Review ST definitions & productsReview ST definitions & products

• Discuss the prevalence of ST useDiscuss the prevalence of ST use

• Describe ST pharmacologyDescribe ST pharmacology

• Discuss ST dependence measures and Discuss ST dependence measures and withdrawalwithdrawal

• Review recommended treatments for ST useReview recommended treatments for ST use

ST Definitions & ProductsST Definitions & ProductsST Definitions & ProductsST Definitions & Products

Spit Tobacco - Definitions

• ““Smokeless” - industry termSmokeless” - industry term– Implies safetyImplies safety– Could be replaced with “spit”Could be replaced with “spit”

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

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

Smokeless Brand Used Most Often in Smokeless Brand Used Most Often in Last MonthLast Month

Column 2

Column 2 moist snuff chew dry snuff/other

Column 2

Column 2 moist snuff chew dry snuff/other

National Household Survey on Drug Abuse, 2000

Preferred Snuff ProductsPreferred Snuff ProductsPreferred Snuff ProductsPreferred Snuff Products

Column 2

Column 2 Skoal Copenhagen Kodiak

Timber Wolf Red Seal Hawken

Silver Creek Rooster

Column 2

Column 2 Skoal Copenhagen Kodiak

Timber Wolf Red Seal Hawken

Silver Creek Rooster

National Household Survey on Drug Abuse, 2001

Chewing Tobacco ProductsChewing Tobacco ProductsChewing Tobacco ProductsChewing Tobacco Products

Column 2

Column 2 Red Man Beech Nut Levi Garrett

Apple Jack Blackbull Southern Pride

Column 2

Column 2 Red Man Beech Nut Levi Garrett

Apple Jack Blackbull Southern Pride

Prevalence of ST UsePrevalence of ST UsePrevalence of ST UsePrevalence of ST Use

Background - PrevalenceBackground - PrevalenceBackground - PrevalenceBackground - Prevalence

• In the U.S., 1991:In the U.S., 1991:• 5.3 million people regularly used ST5.3 million people regularly used ST

• By the year 2001, among individuals By the year 2001, among individuals >> 12 years of 12 years of age:age:

• 7.3 million regular ST users 7.3 million regular ST users [[Results from the 2001 National Household Survey Results from the 2001 National Household Survey

on Drug Abuse: Volume I. Summary of National Findingson Drug Abuse: Volume I. Summary of National Findings (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]SMA 02-3758). Rockville, MD.]

• In the U.S., 1991:In the U.S., 1991:• 5.3 million people regularly used ST5.3 million people regularly used ST

• By the year 2001, among individuals By the year 2001, among individuals >> 12 years of 12 years of age:age:

• 7.3 million regular ST users 7.3 million regular ST users [[Results from the 2001 National Household Survey Results from the 2001 National Household Survey

on Drug Abuse: Volume I. Summary of National Findingson Drug Abuse: Volume I. Summary of National Findings (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]SMA 02-3758). Rockville, MD.]

• Among individuals Among individuals >> 12 years of age: 12 years of age:• 6.3% males6.3% males• 0.4% females0.4% females[[[[Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National FindingsResults from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings (Office of (Office of

Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]

• Highest rates of current ST use are found in American Highest rates of current ST use are found in American Indians and Alaska Natives.Indians and Alaska Natives.

• Northern Plains Native Americans: 25% prevalence of Northern Plains Native Americans: 25% prevalence of adult men adult men [USDHHS, 1998][USDHHS, 1998]

• Among individuals Among individuals >> 12 years of age: 12 years of age:• 6.3% males6.3% males• 0.4% females0.4% females[[[[Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National FindingsResults from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings (Office of (Office of

Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758). Rockville, MD.]

• Highest rates of current ST use are found in American Highest rates of current ST use are found in American Indians and Alaska Natives.Indians and Alaska Natives.

• Northern Plains Native Americans: 25% prevalence of Northern Plains Native Americans: 25% prevalence of adult men adult men [USDHHS, 1998][USDHHS, 1998]

Past Month Tobacco Use among Persons Past Month Tobacco Use among Persons Aged 12 or Older: 2001Aged 12 or Older: 2001

• ST use is higher in rural areas than in urban areas ST use is higher in rural areas than in urban areas [Centers for Disease [Centers for Disease

Control and Prevention, 1993 #1820]Control and Prevention, 1993 #1820]

• Use is reported to be higher in small towns than in large Use is reported to be higher in small towns than in large cities cities [Marcus, 1989 #909][Marcus, 1989 #909]

• The highest prevalence of ST use (after Alaska Natives) is The highest prevalence of ST use (after Alaska Natives) is found among:found among:

• White males between the ages of 18 and 25White males between the ages of 18 and 25• White males between the ages of 25 and 35 White males between the ages of 25 and 35 [Smith, 1999 #3][Smith, 1999 #3]

• ST use is higher in rural areas than in urban areas ST use is higher in rural areas than in urban areas [Centers for Disease [Centers for Disease

Control and Prevention, 1993 #1820]Control and Prevention, 1993 #1820]

• Use is reported to be higher in small towns than in large Use is reported to be higher in small towns than in large cities cities [Marcus, 1989 #909][Marcus, 1989 #909]

• The highest prevalence of ST use (after Alaska Natives) is The highest prevalence of ST use (after Alaska Natives) is found among:found among:

• White males between the ages of 18 and 25White males between the ages of 18 and 25• White males between the ages of 25 and 35 White males between the ages of 25 and 35 [Smith, 1999 #3][Smith, 1999 #3]

• Among the population 12 years of age or older who had used Among the population 12 years of age or older who had used ST in the last month:ST in the last month:

• 0.8% of the Hispanic population 0.8% of the Hispanic population • 1.3% among Hispanic males1.3% among Hispanic males

• 2.0% of the African-Americans2.0% of the African-Americans• 2% among African-American males2% among African-American males

• 0.2% among women 0.2% among women [NHSDA, 1998].[NHSDA, 1998].

• 1.3% among women attending college 1.3% among women attending college [Rigotti, 2000][Rigotti, 2000]

• Among the population 12 years of age or older who had used Among the population 12 years of age or older who had used ST in the last month:ST in the last month:

• 0.8% of the Hispanic population 0.8% of the Hispanic population • 1.3% among Hispanic males1.3% among Hispanic males

• 2.0% of the African-Americans2.0% of the African-Americans• 2% among African-American males2% among African-American males

• 0.2% among women 0.2% among women [NHSDA, 1998].[NHSDA, 1998].

• 1.3% among women attending college 1.3% among women attending college [Rigotti, 2000][Rigotti, 2000]

Background - Marketing & SalesBackground - Marketing & SalesBackground - Marketing & SalesBackground - Marketing & Sales

• In 2001:In 2001:

• Advertising & Promotion = Advertising & Promotion = $236.7 million$236.7 million

• Amount sold = Amount sold = 112 million pounds112 million pounds

• Sales revenues = Sales revenues = $2.13 billion in 2001$2.13 billion in 2001

[Federal Trade Commission, 2001-3][Federal Trade Commission, 2001-3]

• In 2001:In 2001:

• Advertising & Promotion = Advertising & Promotion = $236.7 million$236.7 million

• Amount sold = Amount sold = 112 million pounds112 million pounds

• Sales revenues = Sales revenues = $2.13 billion in 2001$2.13 billion in 2001

[Federal Trade Commission, 2001-3][Federal Trade Commission, 2001-3]

Adverse Health EffectsAdverse Health EffectsAdverse Health EffectsAdverse Health Effects

Smokeless Tobacco - Health Smokeless Tobacco - Health Consequences 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”

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

• CarcinogensCarcinogens

• AldehydesAldehydes

• Tobacco-specific N-nitrosamines (TSNAs)Tobacco-specific N-nitrosamines (TSNAs)• 7 types identified7 types identified

• Polycyclic aromatic hydrocarbonsPolycyclic aromatic hydrocarbons

• Polonium 210Polonium 210

• CarcinogensCarcinogens

• AldehydesAldehydes

• Tobacco-specific N-nitrosamines (TSNAs)Tobacco-specific N-nitrosamines (TSNAs)• 7 types identified7 types identified

• Polycyclic aromatic hydrocarbonsPolycyclic aromatic hydrocarbons

• Polonium 210Polonium 210

ST - Health ConsequencesST - Health Consequences

• Risk appears to be different in different parts of world

• Likely relates to the type of ST use

• U.S. - Snuff & chewing tobacco

• Scandinavia - snus (lower levels of TSNAs)

• India - mixed with more carcingens (i.e., betel)

• Africa - “toombak” (I.e., N. rustica + Na bicarbonate)

• Risk appears to be different in different parts of world

• Likely relates to the type of ST use

• U.S. - Snuff & chewing tobacco

• Scandinavia - snus (lower levels of TSNAs)

• India - mixed with more carcingens (i.e., betel)

• Africa - “toombak” (I.e., N. rustica + Na bicarbonate)

Health Effects of ST: Systematic ReviewHealth Effects of ST: Systematic Review

• Electronic database search, references lists, smoking-related websites, and contacted experts

• Observational studies of ST use with > 500 subjects• Cohorts• Case-control• Cross sectional studies

• Electronic database search, references lists, smoking-related websites, and contacted experts

• Observational studies of ST use with > 500 subjects• Cohorts• Case-control• Cross sectional studies

Critchley et al. Thorax. 2003; 58: 435-443.

SR: Oral and Pharyngeal Cancers - U.S. DataSR: Oral and Pharyngeal 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

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

A - Stockwell et al, 1986

B- Winn et al., 1981

SR: Oral and Pharyngeal Cancers - U.S. DataSR: Oral and Pharyngeal Cancers - U.S. Data

Winn et al., 1981

Cancer of gum and buccal mucosa = dose responseCancer of gum and buccal mucosa = dose response

> 50 years> 50 years

OR = 47.5 (95% CI: 9.1-249.5)OR = 47.5 (95% CI: 9.1-249.5)

1-24 years1-24 years: :

OR = 13.8 (95% CI: 1.9 to 98.0)OR = 13.8 (95% CI: 1.9 to 98.0)

SR: Cancer Other Sites - U.S. DataSR: Cancer Other Sites - U.S. Data

Bladder 4.0 (1.1-14.2)

Goodman et al., 1986

SR: Cardiovascular Disease - ScandinaviaSR: Cardiovascular Disease - Scandinavia

• Current/exclusive use compared w/ never smokers

• 35-54 year olds: • Ischemic heart disease: RR 2.0 (95% CI: 1.49-2.9)• Cardiovascular death: RR 2.1 (95% CI: 1.5-2.9)

• 55-64 year olds:• IHD: RR 1.2 (95% CI: 1.0-1.5)• CVD: RR 1.1 (95% CI: 1.0-1.4)

• Current/exclusive use compared w/ never smokers

• 35-54 year olds: • Ischemic heart disease: RR 2.0 (95% CI: 1.49-2.9)• Cardiovascular death: RR 2.1 (95% CI: 1.5-2.9)

• 55-64 year olds:• IHD: RR 1.2 (95% CI: 1.0-1.5)• CVD: RR 1.1 (95% CI: 1.0-1.4)

Bolinder et al., 1994

SR: Dental Disease - U.S. DataSR: Dental Disease - U.S. Data

• Dental disease = caries & periodontal disease

• Decayed root surfaces: OR 3.24 (95% CI: 2.0-4.4)A

• Periodontal disease:

• Attachment loss more common in ST users without oral lesions than non-users (33.6% vs. 27.4%, P < 0.05)B

• Dental disease = caries & periodontal disease

• Decayed root surfaces: OR 3.24 (95% CI: 2.0-4.4)A

• Periodontal disease:

• Attachment loss more common in ST users without oral lesions than non-users (33.6% vs. 27.4%, P < 0.05)B

A - Tomar et al., 1999

B - Ernster et al., 1990

SR: Oral Cancer Deaths……… SR: Oral Cancer Deaths………

Critchley et al., 2003

Location, Location, Location

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

• LeukoplakiaLeukoplakia

• ErythroleukoplakiaErythroleukoplakia

• 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

ST PharmacologyST PharmacologyST PharmacologyST Pharmacology

Smokeless Tobacco PharmacologySmokeless Tobacco PharmacologySmokeless Tobacco PharmacologySmokeless Tobacco Pharmacology

• Potential available nicotine is twice that obtained from Potential available nicotine is twice that obtained from smoking a cigarette:smoking a cigarette:

chewing tobaccochewing tobacco 4.5 mg4.5 mg

moist snuffmoist snuff 3.6 mg3.6 mg

4 mg nicotine gum4 mg nicotine gum 1.9 mg1.9 mg

cigarettecigarette 1.8 mg 1.8 mg

• Potential available nicotine is twice that obtained from Potential available nicotine is twice that obtained from smoking a cigarette:smoking a cigarette:

chewing tobaccochewing tobacco 4.5 mg4.5 mg

moist snuffmoist snuff 3.6 mg3.6 mg

4 mg nicotine gum4 mg nicotine gum 1.9 mg1.9 mg

cigarettecigarette 1.8 mg 1.8 mg

4.8 mg nicotine/gm of moist snuff x 30 gm/can = 144 mg4.8 mg nicotine/gm of moist snuff x 30 gm/can = 144 mg

144 mg nicotine/(1.8 mg nicotine/cigarette) = 80 cigarettes144 mg nicotine/(1.8 mg nicotine/cigarette) = 80 cigarettes

80 cigarettes/(20 cigarettes/pack) = 4 packs80 cigarettes/(20 cigarettes/pack) = 4 packs

1 can snuff = 4 packs of cigarettes1 can snuff = 4 packs of cigarettes

3 cans/day = As much nicotine as 12 packs of cigarettes3 cans/day = As much nicotine as 12 packs of cigarettes

• Slower absorption than with smokingSlower absorption than with smoking

• Peak concentration at 30 minutesPeak concentration at 30 minutes

• Persistent absorption for up to 60 minutes after Persistent absorption for up to 60 minutes after tobacco removedtobacco removed

• slow release from mucous membranesslow release from mucous membranes• absorption of swallowed nicotineabsorption of swallowed nicotine

• Slower absorption than with smokingSlower absorption than with smoking

• Peak concentration at 30 minutesPeak concentration at 30 minutes

• Persistent absorption for up to 60 minutes after Persistent absorption for up to 60 minutes after tobacco removedtobacco removed

• slow release from mucous membranesslow release from mucous membranes• absorption of swallowed nicotineabsorption of swallowed nicotine

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 et al, 1988.

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)

• Lower acid level of product - higher free nicotineLower acid level of product - higher free nicotine

• 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)

• Lower acid level of product - higher free nicotineLower acid level of product - higher free nicotine

Free Nicotine as a Function of pH

UST’s “graduation strategy” in a UST document exhibited in the Marsee vs US Tobacco Company Lawsuit, 1986

Connolly, G. N. (1995). “The marketing of nicotine addiction by one oral snuff manufacturer.” Tob Control 4: 73-79.

Fant, RV et al. Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tobacco Control 1999; 8: 387-392.

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, S. L., G. A. Giovino, et al. (1995). “Smokeless tobacco brand preference and brand switching among US adolescents and young adults.” Tob Control 4: 67-72.

ST Dependence & WithdrawalST Dependence & WithdrawalST Dependence & WithdrawalST Dependence & Withdrawal

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

CravingIrritabilityIncreased eatingAnxietyImpatienceRestlessnessDepressed moodDifficulty concentratingDisrupted sleep

Ebbert et al.

Measuring Dependence in ST UsersMeasuring Dependence in ST UsersMeasuring Dependence in ST UsersMeasuring Dependence in ST Users

• Predictors of nicotine dependence (modified FTQ)Predictors of nicotine dependence (modified FTQ)

• Using ST within 30 minutes of waking upUsing ST within 30 minutes of waking up• Higher number of tins per weekHigher number of tins per week• Always swallowing tobacco juiceAlways swallowing tobacco juice

Boyle et al. Addictive Behaviors. Vol. 20, No. 4, pp. 443-450. 1995

Measuring Dependence in ST UsersMeasuring Dependence in ST UsersMeasuring Dependence in ST UsersMeasuring Dependence in ST Users

• Using ST within 30 minutes of waking upUsing ST within 30 minutes of waking up• Higher number of tins per weekHigher number of tins per week• Always swallowing tobacco juiceAlways swallowing tobacco juice• Using in inappropriate placesUsing in inappropriate places

• Church, synagogue, mosqueChurch, synagogue, mosque• Using ST when ill in bedUsing ST when ill in bed• Nicotine contentNicotine content

• Copenhagen > Skoal banditsCopenhagen > Skoal bandits• Chewing more in the morning Chewing more in the morning • Morning chews are harder to give upMorning chews are harder to give up• Chewing more than 16 hours/dayChewing more than 16 hours/day

• Using ST within 30 minutes of waking upUsing ST within 30 minutes of waking up• Higher number of tins per weekHigher number of tins per week• Always swallowing tobacco juiceAlways swallowing tobacco juice• Using in inappropriate placesUsing in inappropriate places

• Church, synagogue, mosqueChurch, synagogue, mosque• Using ST when ill in bedUsing ST when ill in bed• Nicotine contentNicotine content

• Copenhagen > Skoal banditsCopenhagen > Skoal bandits• Chewing more in the morning Chewing more in the morning • Morning chews are harder to give upMorning chews are harder to give up• Chewing more than 16 hours/dayChewing more than 16 hours/day

Boyle et al. Addictive Behaviors. Vol. 20, No. 4, pp. 443-450. 1995

Current Recommendations for Current Recommendations for TreatmentTreatment

Methods of Treating Smokeless Tobacco UseMethods of Treating Smokeless Tobacco UseMethods of Treating Smokeless Tobacco UseMethods of Treating Smokeless Tobacco Use

Behavioral

Pharmacologic

Literature ReviewLiterature ReviewLiterature ReviewLiterature Review

• ““What interventions are effective for ST users?”What interventions are effective for ST users?”

• Two systematic reviews of treatment:Two systematic reviews of treatment:• Ebbert, J. O., L. C. Rowland, et al. (2003). Ebbert, J. O., L. C. Rowland, et al. (2003).

“Treatments for spit tobacco use: a “Treatments for spit tobacco use: a quantitative systematic review.” quantitative systematic review.” AddictionAddiction 9898(5): 569-83.(5): 569-83.

• Severson, H. H. (2003). “What have we Severson, H. H. (2003). “What have we learned from 20 years of research on learned from 20 years of research on smokeless tobacco cessation?” smokeless tobacco cessation?” Am J Med Am J Med SciSci 326326(4): 206-11.(4): 206-11.

• ““What interventions are effective for ST users?”What interventions are effective for ST users?”

• Two systematic reviews of treatment:Two systematic reviews of treatment:• Ebbert, J. O., L. C. Rowland, et al. (2003). Ebbert, J. O., L. C. Rowland, et al. (2003).

“Treatments for spit tobacco use: a “Treatments for spit tobacco use: a quantitative systematic review.” quantitative systematic review.” AddictionAddiction 9898(5): 569-83.(5): 569-83.

• Severson, H. H. (2003). “What have we Severson, H. H. (2003). “What have we learned from 20 years of research on learned from 20 years of research on smokeless tobacco cessation?” smokeless tobacco cessation?” Am J Med Am J Med SciSci 326326(4): 206-11.(4): 206-11.

Literature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: Conclusions

Severson, H. H. (2003). “What have we learned from 20 years of research on smokeless tobacco cessation?” Am J Med Sci 326(4): 206-11.

Literature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: Conclusions

• Meta-analyses:Meta-analyses:

• Behavioral interventions Behavioral interventions areare effective. effective.• Bupropion SR Bupropion SR is probablyis probably effective intervention effective intervention

for ST users. for ST users. • NRT NRT may bemay be an effective intervention for ST an effective intervention for ST

users.users.• Among the behavioral interventions, the use of an Among the behavioral interventions, the use of an

oral examination appears to be associated with oral examination appears to be associated with the greatest treatment effect.the greatest treatment effect.

• Meta-analyses:Meta-analyses:

• Behavioral interventions Behavioral interventions areare effective. effective.• Bupropion SR Bupropion SR is probablyis probably effective intervention effective intervention

for ST users. for ST users. • NRT NRT may bemay be an effective intervention for ST an effective intervention for ST

users.users.• Among the behavioral interventions, the use of an Among the behavioral interventions, the use of an

oral examination appears to be associated with oral examination appears to be associated with the greatest treatment effect.the greatest treatment effect.

Ebbert, J. O., L. C. Rowland, et al. (2003). “Treatments for spit tobacco use: a quantitative systematic review.” Ebbert, J. O., L. C. Rowland, et al. (2003). “Treatments for spit tobacco use: a quantitative systematic review.” AddictionAddiction 9898(5): 569-83.(5): 569-83.

Pharmacologic TreatmentPharmacologic Treatment::

Nicotine Patch Percentage Nicotine Patch Percentage ReplacementReplacement

Pharmacologic TreatmentPharmacologic Treatment::

Nicotine Patch Percentage Nicotine Patch Percentage ReplacementReplacement

Peak serumPeak serumnicotinenicotine

concentrationsconcentrations(ng/mL)(ng/mL)

Cans or pouchesCans or pouchesper weekper week Patch dosePatch dose

LowLow 0-100-10 = 1= 1 14 mg/d14 mg/d

IntermediateIntermediate 11-2011-20 2-32-3 21or 22 mg/d21or 22 mg/d

HighHigh > 20> 20 > 3> 3 42 or 44 mg/d42 or 44 mg/d

NRT for ST Users

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

Oral ExamOral Exam

• Oral exam .pdf available at:

• http://www.nohic.nidcr.nih.gov/pdfs/OralPoster2002.pdf

• Oral exam .pdf available at:

• http://www.nohic.nidcr.nih.gov/pdfs/OralPoster2002.pdf

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

Nicotine LozengeDosing

• 1-2 lozenges every 1-2 hours

• Minimum of 9/day

• Taper over 12 weeks

• 1-2 lozenges every 1-2 hours

• Minimum of 9/day

• Taper over 12 weeks

Nicotine LozengeSide-Effects

• Nausea (12-15%)

• Heartburn (5-6%)

• Hiccups (3-8%)

• Not to be chewed or swallowed whole

• Avoid eating or drinking food during and 15 minutes prior to use

• Nausea (12-15%)

• Heartburn (5-6%)

• Hiccups (3-8%)

• Not to be chewed or swallowed whole

• Avoid eating or drinking food during and 15 minutes prior to use

Nicotine GumNicotine Gum

• Useful adjunct with interventionUseful adjunct with intervention

• Most effective with counselingMost effective with counseling

• 2 mg and 4 mg2 mg and 4 mg

• ““Chew and Park”Chew and Park”

• Frequent use initially (10-15/day)Frequent use initially (10-15/day)

• Often used in combination with other NRTOften used in combination with other NRT

Nicotine GumNicotine Gum: Side EffectsNicotine GumNicotine Gum: Side Effects

• mouth soreness

• hiccups

• stomach upset/nausea

• jaw aches

• mouth soreness

• hiccups

• stomach upset/nausea

• jaw aches

Bupropion SRBupropion SRDosing

150 mg daily for 3-4 days

150 mg twice a day for 3-4 days

STOP Tobacco

150 mg daily for 3-4 days

150 mg twice a day for 3-4 days

STOP Tobacco

BupropionBupropionSide EffectsSide Effects

• Insomnia (35%)

• Dry mouth (13%)

• Anxiety (5%)

• Rash (2%)

• Seizures: 1/1000

• Insomnia (35%)

• Dry mouth (13%)

• Anxiety (5%)

• Rash (2%)

• Seizures: 1/1000

BupropionBupropionSeizure Risk

• History of seizures

• Previous head/CNS trauma

• Eating disorders (bulimia/anorexia nervosa)

• Neuroleptic medications

• High doses of Bupropion

• History of seizures

• Previous head/CNS trauma

• Eating disorders (bulimia/anorexia nervosa)

• Neuroleptic medications

• High doses of Bupropion

Bupropion SRBupropion SRDosing

• Duration: 8-12 weeks

• Safe to use longer

• Taper is unnecessary

• Combination with NRT

• Duration: 8-12 weeks

• Safe to use longer

• Taper is unnecessary

• Combination with NRT

• Pilot projectPilot project

• 8-day inpatient program8-day inpatient program

• Didactics, group therapy/individual therapyDidactics, group therapy/individual therapy

• Tailored pharmacotherapyTailored pharmacotherapy

• Combination (bupropion & NRT)Combination (bupropion & NRT)

• Percentage replacementPercentage replacement

• Dental hygienist visit and a dental examination with Dental hygienist visit and a dental examination with

photographs of suspicious lesions.photographs of suspicious lesions.

Residential Treatment Program

• 3-month self-reported continuous abstinence rate:3-month self-reported continuous abstinence rate:

• 22/24 = 92%22/24 = 92%

• 6-month self-reported continuous abstinence rate:6-month self-reported continuous abstinence rate:

• 21/24 = 88%21/24 = 88%

• 12-month 12-month biochemically-confirmedbiochemically-confirmed point prevalence point prevalence

tobacco abstinence rate:tobacco abstinence rate:

• 12/24 = 50%12/24 = 50%

Results

“Paul”“Paul”

• 34 years old

• Spit tobacco for 28 years

• Now: Copenhagen 1 tin/day

• Quit attempts: 4-5, longest 2 days

• Exam: plaque, supragingival calculus, erythema and inflamed tissue, areas of leukoplakia on the labial vestibule opposite lower incisors

• 34 years old

• Spit tobacco for 28 years

• Now: Copenhagen 1 tin/day

• Quit attempts: 4-5, longest 2 days

• Exam: plaque, supragingival calculus, erythema and inflamed tissue, areas of leukoplakia on the labial vestibule opposite lower incisors

• Nicotine Level: 40 ng/ml

• Cotinine Level: 402 ng/ml

• Treatment: • Bupropion SR 150 bid• Residential Program• 42 mg nicotine patch• Nicotine gum as needed• Snuff substitute as needed

• Nicotine Level: 40 ng/ml

• Cotinine Level: 402 ng/ml

• Treatment: • Bupropion SR 150 bid• Residential Program• 42 mg nicotine patch• Nicotine gum as needed• Snuff substitute as needed

• Day 2: Difficulty sleeping, strong cravings, constantly thinking about Copenhagen. Using mint snuff oral substitute.

• Plan: Increase to 56 mg nicotine patch/day

• Day 2: Difficulty sleeping, strong cravings, constantly thinking about Copenhagen. Using mint snuff oral substitute.

• Plan: Increase to 56 mg nicotine patch/day

• Day 4: Slept much better. Significant decrease in cravings. Continues with snuff substitute.

• Nicotine level: 37 ng/ml

• Cotinine level: 318 ng/ml

• Day 4: Slept much better. Significant decrease in cravings. Continues with snuff substitute.

• Nicotine level: 37 ng/ml

• Cotinine level: 318 ng/ml

• Day 8: Dismiss on 56mg/day nicotine patch for 4 weeks and then taper as tolerated; bupropion SR 150 bid for at least 3 months. Follow-up with counselor regularly by telephone.

Goals & ObjectivesGoals & ObjectivesGoals & ObjectivesGoals & Objectives

© 2003 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED Smokeless (Spit)...

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