nausea. Nausea and insomnia are common side effects and are usually transient. If the side effects are severe or persistent, patients should notify the dentist or physician so that a dose reduction can be considered. 78,80 Combination pharmacotherapy Evidence indicates that using a combination of medications for smoking cessation significantly increases the likelihood of abstinence. 1,60 The decision to use medications in combination should be based on the clinician’s and patient’s perceptions of the adequacy of control of tobacco withdrawal symptoms. Consideration for the use of medications in combination should include the increased cost of medications and the possibility of increased side effects. 11 Approved combination medications include any of the following: ● Varenicline plus Bupropion. ● Long-term (greater than 14 weeks) nicotine patch plus another form of nicotine replacement (nicotine gum and nicotine spray). From a clinical standpoint, findings from Cahill and colleagues’ 2013 meta-analysis are very relevant. These authors found that there is a low – but real – risk of neuropsychiatric disorders with the use of verinicline and bupropion and that combination nicotine replacement therapy seems to be as effective as the use of verinicline alone. Guo and colleagues additionally found that Varenicline tends to commonly cause insomnia while Bupropion tends to cause headaches. ● Nicotine patch plus the nicotine inhaler. ● Nicotine patch plus bupropion SR. 11
There have been infrequent reports of life-threatening angioedema requiring emergent medical attention due to respiratory compromise. Clinical signs included swelling of the face, mouth (tongue, lips, and gums), extremities, and neck (throat and larynx). In such cases, the patient should be instructed to discontinue the medication and seek immediate medical care. For patients with severe renal impairment, the recommended starting dose is 0.5 mg once daily. The dose may then be titrated as needed to a maximum dose of 0.5 mg twice a day. For patients with end-stage renal disease undergoing hemodialysis, a maximum dose of 0.5 mg once daily may be administered if tolerated. 76 No dosage adjustment is necessary for patients with hepatic impairment. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and renal function should be monitored. 76 Side effects The most common adverse reactions are nausea, abnormal (e.g., vivid, unusual, or strange) dreams, constipation, flatulence, and vomiting. Nausea is the most common adverse reaction (up to 30% incidence rate). Dose reduction may be helpful. 78,80 Patient instructions Varenicline therapy should begin 1 week prior to the quit date. One 0.5-mg tablet should be taken daily for the first 3 days. For the next 4 days, one 0.5-mg tablet should be taken in the morning and one 0.5-mg tablet should be taken in the evening. After the first 7 days, the dose should be increased to one 1-mg tablet in the morning and one 1-mg tablet in the evening. This regimen should be continued through the end of treatment. It is important that varenicline be taken after eating and with a full glass of water to reduce
SMOKELESS TOBACCO INTRODUCTION
tobacco comprises approximately 22% of the U.S. smokeless tobacco market. 83 ● Plug chewing tobacco : Consists of small, oblong blocks of semisoft chewing tobacco that often contain sweeteners and other flavoring agents. ● Snus : Is a tea bag-like packet of moist snuff tobacco and flavorings, placed between the upper gum and lip. This product does not require the user to spit, unlike traditional moist snuff. This is a relatively new product in the smokeless tobacco market. According to the 2011 Monitoring the Future survey, 5.8% of 1,800 males aged 19 to 30 reported using snus. 84 ● Dissolvable tobacco products : Are made of ground tobacco and flavorings, shaped into pellets, strips, or other forms that the user ingests orally. These products also do not require spitting. They are the most recently introduced products in the smokeless tobacco market. According to the 2011 Monitoring the Future survey, 0.4% of 1,800 males aged 19 to 30 reported using dissolvable tobacco products. 84
The term smokeless tobacco is used to refer to those forms of tobacco that are consumed without combustion (burning). Nicotine from smokeless tobacco is absorbed into the body through the oral mucosa when the tobacco is placed in the mouth. A variety of smokeless tobacco products are manufactured and sold in the United States. The five forms collectively referred to as smokeless tobacco are listed below: 82 ● Oral (moist) snuff : Is a finely cut, processed tobacco, which is placed between the cheek and gum and releases nicotine that is absorbed by the oral mucosa, as is the case with all forms of smokeless tobacco. This type of smokeless tobacco constitutes 85.6% of the smokeless tobacco sold in the United States. 83 ● Loose leaf chewing tobacco : Is stripped and processed cigar-type tobacco leaves, loosely packed to form small strips. It is often sold in a foil-lined pouch and usually treated with sugar or licorice. Loose leaf chewing
SMOKELESS TOBACCO PREVALENCE
Three national surveys show that smokeless tobacco use has increased in high school-aged youth. The 2020 Youth Risk Behavior survey reported that 1.7% of U.S. high school boys currently use smokeless tobacco products. Use was particularly high in some states, including Kentucky (7%), Mississippi (7.4%), West Virginia (8.3%), and Wyoming (8.8%). 85 According to the 2011 Monitoring the Future survey, there was a 36.0% increase in smokeless tobacco use in 12th graders from 2006 (6.1%) to 2011 (8.3%). Among 10th graders, there was a 34.7% increase in smokeless tobacco use from 2004 to 2010 (4.9% to 6.6%). 86 Similarly, the 2009
National Survey on Drug Use and Health reported that the number of boys aged 12 to 17 starting to use smokeless tobacco has significantly increased since 2002. Youth aged 12 to 17 were more likely to start using smokeless tobacco compared to 18- to 25-year olds. Smoking among high school boys declined 17.4% between 2003 and 2011, while smokeless tobacco use among high school boys increased 16.4% over the same time period. 89 From 2002 to 2007, more than half (52.8%) of youth aged 12 to 17 who used smokeless tobacco in the past month also reported past month cigarette smoking. 87 This stagnation in youth cigarette smoking, coupled with an
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