1 Treatment of Spit Tobacco Use Lowell C. Dale, MD Lowell C. Dale, MD Jon O. Ebbert, MD, MSc Jon O. Ebbert, MD, MSc Assistant Professors of Medicine, Mayo Medical Assistant Professors of Medicine, Mayo Medical School School Community Internal Medicine & Nicotine Community Internal Medicine & Nicotine Dependence Center Dependence Center
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1 Treatment of Spit Tobacco Use Lowell C. Dale, MD Jon O. Ebbert, MD, MSc Assistant Professors of Medicine, Mayo Medical School Community Internal Medicine.
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Treatment of Spit Tobacco UseTreatment of Spit Tobacco Use
Lowell C. Dale, MDLowell C. Dale, MD
Jon O. Ebbert, MD, MScJon O. Ebbert, MD, MSc
Assistant Professors of Medicine, Mayo Medical SchoolAssistant Professors of Medicine, Mayo Medical School
Community Internal Medicine & Nicotine Dependence CenterCommunity Internal Medicine & Nicotine Dependence Center
Lowell C. Dale, MDLowell C. Dale, MD
Jon O. Ebbert, MD, MScJon O. Ebbert, MD, MSc
Assistant Professors of Medicine, Mayo Medical SchoolAssistant Professors of Medicine, Mayo Medical School
Community Internal Medicine & Nicotine Dependence CenterCommunity Internal Medicine & Nicotine Dependence Center
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 2
• In 1999, newspaper, magazine, and point of sale advertising approached $170 million.
• Annual revenues from ST sales peaked at $1,940 million.
[Federal Trade Commission, 2001]
• In 1999, newspaper, magazine, and point of sale advertising approached $170 million.
• Annual revenues from ST sales peaked at $1,940 million.
[Federal Trade Commission, 2001]
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Who Uses ST?Who Uses ST?
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 7
Background - PrevalenceBackground - Prevalence
• In the U.S., 1991:• 5.3 million people regularly used ST
• By the year 2000, among individuals > 12 years of age:
• 7.6 million regular ST users [USDHSS, 2000; U.S. Census, 2000]
• In the U.S., 1991:• 5.3 million people regularly used ST
• By the year 2000, among individuals > 12 years of age:
• 7.6 million regular ST users [USDHSS, 2000; U.S. Census, 2000]
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 8
Background - PrevalenceBackground - Prevalence
• Among individuals > 12 years of age:• 6.5% males• 0.5% females
• Highest rates of current ST use are found in American Indians and Alaska Natives.
• Northern Plains Native Americans: 25% prevalence of adult men [USDHHS, 1998]
• Among individuals > 12 years of age:• 6.5% males• 0.5% females
• Highest rates of current ST use are found in American Indians and Alaska Natives.
• Northern Plains Native Americans: 25% prevalence of adult men [USDHHS, 1998]
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 9
Background - PrevalenceBackground - Prevalence
• ST use is higher in rural areas than in urban areas [Centers for Disease
Control and Prevention, 1993 #1820]
• Use is reported to be higher in small towns than in large cities [Marcus, 1989 #909]
• The highest prevalence of ST use is found among:• White males between the ages of 18 and 25• White males between the ages of 25 and 35 [Smith, 1999 #3]
• ST use is higher in rural areas than in urban areas [Centers for Disease
Control and Prevention, 1993 #1820]
• Use is reported to be higher in small towns than in large cities [Marcus, 1989 #909]
• The highest prevalence of ST use is found among:• White males between the ages of 18 and 25• White males between the ages of 25 and 35 [Smith, 1999 #3]
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 10
Background - PrevalenceBackground - Prevalence
• Among the population 12 years of age or older who had used ST in the last month:
• 0.8% of the Hispanic population • 1.3% among Hispanic males
• 2.0% of the African-Americans• 2% among African-American males, and
• 0.2% among all women [NHSDA, 1998 #2173].
• The prevalence of ST use within the past year among college-age women was 1.3% [Rigotti, 2000 #2031].
• Among the population 12 years of age or older who had used ST in the last month:
• 0.8% of the Hispanic population • 1.3% among Hispanic males
• 2.0% of the African-Americans• 2% among African-American males, and
• 0.2% among all women [NHSDA, 1998 #2173].
• The prevalence of ST use within the past year among college-age women was 1.3% [Rigotti, 2000 #2031].
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 11
Background - Health ImplicationsBackground - Health Implications
• Use of ST products can lead to:• Nicotine addiction
• ST use is a risk factor for:• Periodontal disease• Tooth decay• Oral cancer [National Institute of Health, 1986]
• Use of ST products can lead to:• Nicotine addiction
• ST use is a risk factor for:• Periodontal disease• Tooth decay• Oral cancer [National Institute of Health, 1986]
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 12
Spit Tobacco: Health EffectsSpit Tobacco: Health Effects
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 13
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 14
LeukoplakiaLeukoplakia
• Silverman et al., 1984• Followed 257 patients w/ leukoplakia• 7.2 years on average• 45 (17.5%) developed SCC
• Conservative estimates: 3-6%
• Silverman et al., 1984• Followed 257 patients w/ leukoplakia• 7.2 years on average• 45 (17.5%) developed SCC
• Conservative estimates: 3-6%
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 15
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 16
Spit Tobacco: Health EffectsSpit Tobacco: Health Effects
Oral Cancer
• 4 fold increase in moderate ST Users• 7 fold increase in
heavy ST Users
Oral Cancer
• 4 fold increase in moderate ST Users• 7 fold increase in
heavy ST Users
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 17
Background - Health ImplicationsBackground - Health Implications
• May increase the risk for cancer of the:• Esophagus• Larynx• Stomach• Pancreas [Connolly, 1986; Mattson, 1989]
• May increase the risk for cancer of the:• Esophagus• Larynx• Stomach• Pancreas [Connolly, 1986; Mattson, 1989]
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 18
Background - Health ImplicationsBackground - Health Implications
• ST use associated with risk factors for cardiovascular disease
• Elevated blood pressure and cholesterol levels.[Bolinder, 1992; Bolinder, 1994; Tucker, 1989; National Institute of Health, 1986]
• Laboratory rat models - ST extracts exhibit adverse effects on fetal viability and development.[Paulson, 1988]
• ST use associated with risk factors for cardiovascular disease
• Elevated blood pressure and cholesterol levels.[Bolinder, 1992; Bolinder, 1994; Tucker, 1989; National Institute of Health, 1986]
• Laboratory rat models - ST extracts exhibit adverse effects on fetal viability and development.[Paulson, 1988]
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ST PharmacologyST Pharmacology
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 20
Biomarkers: Nicotine vs. CotinineBiomarkers: Nicotine vs. Cotinine
• Nicotine• Direct measurement of the addictive drug• Extensive first pass hepatic metabolism• Half-life 120 minutes
• Cotinine• Major metabolite of nicotine• Pharmacologically inactive• Quantitative marker of nicotine intake• Pre-abstinence levels correlate with withdrawal and
treatment outcome in smokers• Half-life 18-20 hours
• Clinically more practical to measure
• Nicotine• Direct measurement of the addictive drug• Extensive first pass hepatic metabolism• Half-life 120 minutes
• Cotinine• Major metabolite of nicotine• Pharmacologically inactive• Quantitative marker of nicotine intake• Pre-abstinence levels correlate with withdrawal and
treatment outcome in smokers• Half-life 18-20 hours
• Clinically more practical to measure
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 21
CotinineCotinine
• Serum cotinine concentrations have been shown to be associated with relapse to smoking and level of dependence in smokers.
• ST users swallow a large amount of nicotine• First-pass hepatic metabolism• Cotinine levels may not accurately reflect
levels of CNS exposure to nicotine
• Serum cotinine concentrations have been shown to be associated with relapse to smoking and level of dependence in smokers.
• ST users swallow a large amount of nicotine• First-pass hepatic metabolism• Cotinine levels may not accurately reflect
levels of CNS exposure to nicotine
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 22
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.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 25
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 26Benowitz et al, 1989.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 27
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 29
CDC, 1999.
Free Nicotine as a Function of pH
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 30
Fant, RV et al. Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tobacco Control 1999; 8: 387-392.
Nicotine PharmacologyDifferent ST Products
Nicotine PharmacologyDifferent ST Products
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ST Dependence & WithdrawalST Dependence & Withdrawal
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 32
Measuring Dependence in ST UsersMeasuring Dependence in ST Users
• Predictors of nicotine dependence (modified FTQ)• Using ST within 30 minutes of waking up• Using ST when sick/mouth sores• ST in mouth > 30 minutes• Intentionally swallowing tobacco juice• ST in mouth all day• Strong cravings when abstinent • Greater than 15 dips/day
• Predictors of nicotine dependence (modified FTQ)• Using ST within 30 minutes of waking up• Using ST when sick/mouth sores• ST in mouth > 30 minutes• Intentionally swallowing tobacco juice• ST in mouth all day• Strong cravings when abstinent • Greater than 15 dips/day
Boyle, 1995
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 33
Frequency of Withdrawal Symptoms in ST UsersFrequency of Withdrawal Symptoms in ST Users
• 85% Strong need/urge
• 63% Irritability
• 55% Restless
• 41% Concentration difficulties
• 39% Hunger
• 9% Sadness/depressed
• 85% Strong need/urge
• 63% Irritability
• 55% Restless
• 41% Concentration difficulties
• 39% Hunger
• 9% Sadness/depressed
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What are Challenges to Treating or Addressing the Needs of ST Users?What are Challenges to Treating or Addressing the Needs of ST Users?
What are Potential Solutions?What are Potential Solutions?
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 35
Literature ReviewLiterature Review
• Question:
“What interventions are effective for ST users?”
• Searched for and identified all randomized controlled trials treating ST users only.
• Question:
“What interventions are effective for ST users?”
• Searched for and identified all randomized controlled trials treating ST users only.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 36
Literature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: Conclusions
• Meta-analyses:
• Bupropion SR may be an effective intervention for ST users.
• NRT may be an effective intervention for ST users.
• Behavioral interventions are effective. • Among the behavioral interventions, the use of an
oral examination appears to be associated with the greatest treatment effect.
• Meta-analyses:
• Bupropion SR may be an effective intervention for ST users.
• NRT may be an effective intervention for ST users.
• Behavioral interventions are effective. • Among the behavioral interventions, the use of an
oral examination appears to be associated with the greatest treatment effect.
Ebbert et al., 2002. Addiction.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 37
Literature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: ConclusionsLiterature Review: Conclusions
• Behavioral Interventions with largest effect:
• Severson, 1998: Usual dental care and office intervention (advice to quit, quit date setting), self-help materials (pamphlets and oral replacement), self-help video & telephone support compared with usual care.
• Walsh, 1999: Oral examination with feedback, photos of ST effects, advice to quit, self-help manual, optional brief counseling (e.g., set quit date, triggers, withdrawal discussion), optional nicotine gum, & telephone support.
• Behavioral Interventions with largest effect:
• Severson, 1998: Usual dental care and office intervention (advice to quit, quit date setting), self-help materials (pamphlets and oral replacement), self-help video & telephone support compared with usual care.
• Walsh, 1999: Oral examination with feedback, photos of ST effects, advice to quit, self-help manual, optional brief counseling (e.g., set quit date, triggers, withdrawal discussion), optional nicotine gum, & telephone support.
Ebbert et al., 2002. Addiction.
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Nicotine Patch Percentage Replacement
Nicotine Patch Percentage Replacement
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 39
Evidence for Inadequate ReplacementEvidence for Inadequate Replacement
Dale et al., 1995.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 40
High Dose NRTInitial Nicotine Patch Dosing Schedule
High Dose NRTInitial Nicotine Patch Dosing Schedule
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 41
Percentage ReplacementPercentage Replacement
• Percentage replacement:
steady state nicotine x 100
baseline nicotine
• Monitor for therapeutic/side effects.
• Percentage replacement:
steady state nicotine x 100
baseline nicotine
• Monitor for therapeutic/side effects.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 42
Percentage ReplacementPercentage Replacement
• Therapeutic drug monitoring with goal of 100% replacement
• ST: serum nicotine test of choice
• Serum nicotine at baseline• Ad libitum ST use
• Choose dose and recheck serum nicotine after 3 days• Steady state
• Therapeutic drug monitoring with goal of 100% replacement
• ST: serum nicotine test of choice
• Serum nicotine at baseline• Ad libitum ST use
• Choose dose and recheck serum nicotine after 3 days• Steady state
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 43
Snuff SubstitutesSnuff Substitutes
• Young’s Chew
• Smokey Mountain
• Golden Eagle
• Oregon Mint
• Winner’s Edge
• Bac-Off
• Jerky
• Sunflower Seeds
• Young’s Chew
• Smokey Mountain
• Golden Eagle
• Oregon Mint
• Winner’s Edge
• Bac-Off
• Jerky
• Sunflower Seeds
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 44
Recommended ST Treatment ApproachRecommended ST Treatment Approach
2) Bupropion• 150 mg po qd x 3 days then bid• Quit 1 week later• Continue for 3-6 months
3) Tailored nicotine patch therapy• +/- gum for self-titration
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 45
“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
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 46
“Paul”“Paul”
• 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
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 47
“Paul”“Paul”
• 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
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 48
“Paul”“Paul”
• 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
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 49
“Paul”“Paul”
• 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.
• Month 4: Continuous abstinence.
• 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.
• Month 4: Continuous abstinence.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 50
• Pilot project
• 8-day inpatient program
• Didactics, group therapy/individual therapy
• Tailored pharmacotherapy
• Combination (bupropion & NRT)
• Percentage replacement
• Dental hygienist visit and a dental examination with photographs
of suspicious lesions.
Residential Treatment Program
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 51
• Oral photographs - individualized feedback
Residential Treatment Program
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 52
• 3 programs - January, February, June
• 24 male ST users
• Median age (IQR): 39 (33-69)
• Median ST use (IQR): 3.5 (2-7) cans/pouches per wk
Results
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 53
Results
54
Case StudiesCase Studies
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 55
Case 1: 16 year-old male Case 1: 16 year-old male
• One pouch Redman Leaf chewing tobacco and/or one tin of Copenhagen per three days x 3 years
• Reason for visit: Second violation for spit tobacco use on school grounds. Off baseball team till addresses tobacco through a program. Mom concerned about use
• History: Hx of asthma, depression, ADHD; sees Psychiatrist, medications - Ritalin
• One pouch Redman Leaf chewing tobacco and/or one tin of Copenhagen per three days x 3 years
• Reason for visit: Second violation for spit tobacco use on school grounds. Off baseball team till addresses tobacco through a program. Mom concerned about use
• History: Hx of asthma, depression, ADHD; sees Psychiatrist, medications - Ritalin
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 56
Case 1: 16 year-old male Case 1: 16 year-old male
• Attempts: Few recalled. Longest abstinence: 3 days
• Withdrawal: more irritable and depressed
• Mood: Likes to see what he can get away with. Most friends use chew; likes to use with them. Thinks he is being treated unfairly.
• Barriers: boredom, peers, perception of enhanced performance
• Attempts: Few recalled. Longest abstinence: 3 days
• Withdrawal: more irritable and depressed
• Mood: Likes to see what he can get away with. Most friends use chew; likes to use with them. Thinks he is being treated unfairly.
• Barriers: boredom, peers, perception of enhanced performance
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How Should We Treat this ST User?How Should We Treat this ST User?
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 58
High Dose NRTInitial Nicotine Patch Dosing Schedule
High Dose NRTInitial Nicotine Patch Dosing Schedule
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 59
Case 2: 49 year-old male Case 2: 49 year-old male
• Seven cans of Copenhagen per week for 15 years
• Reason for visit: wishes to quit because he is concerned about cancer.
• History: Hx of alcoholism associated with withdrawal.
• Seven cans of Copenhagen per week for 15 years
• Reason for visit: wishes to quit because he is concerned about cancer.
• History: Hx of alcoholism associated with withdrawal.
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 60
Case 2: 16 year-old male Case 2: 16 year-old male
• Attempts: none
• Withdrawal: intense cravings
• Barriers: fells it helps keep him motivated at work; outdoor activities (hunting, fishing) are associated with use as well.
• Attempts: none
• Withdrawal: intense cravings
• Barriers: fells it helps keep him motivated at work; outdoor activities (hunting, fishing) are associated with use as well.
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How Should We Treat this ST User?How Should We Treat this ST User?
Dale, Ebbert. Workshop. Treatment of Spit Tobacco Use. 62
High Dose NRTInitial Nicotine Patch Dosing Schedule
High Dose NRTInitial Nicotine Patch Dosing Schedule
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Has this workshop changed your practice or approach to ST users?Has this workshop changed your practice or approach to ST users?