Snus One new product, generically referred to as snus, is a form of oral tobacco originally manufactured and used in Sweden. U.S. tobacco companies are now manufacturing and marketing snus. 103 The tobacco in snus is pasteurized rather than fire-cured. The pasteurization process results in a lower TSNA level than that found in traditional forms of smokeless tobacco. 104 However, snus may be a “starter product” for youth who generally begin with a less potent Dissolvable tobacco Relative newcomers to the smokeless tobacco market are products that dissolve in the mouth, thereby avoiding the need to spit out the juices. These products are made from tobacco but resemble mints, toothpicks, and strips. They should not be confused with nicotine replacement products used for tobacco cessation. The dissolvable products provide an easy way to conceal tobacco use in tobacco- free environments. This is of particular concern in youth tobacco initiation, as the rounds resemble candy that can easily circumvent the restrictions on tobacco use on school property. 107 Unintentional ingestion of tobacco products is a major cause of toxic exposures in children under the age of six in the United States. 108 The candy-like appearance and flavorings of the new dissolvable smokeless tobacco products may Electronic cigarettes An alternative method of nicotine delivery is the use of electronic cigarettes, or e-cigarettes. Smoking, or “vaping,” e-cigarettes has been promoted as being less harmful than the traditional uses of tobacco, but reliable evidence is currently lacking. As stated previously, a detailed discussion of electronic cigarettes is beyond the scope of this course. However, in September of 2014, the National Institute of
product and graduate to other smokeless tobacco products with higher TSNA levels. Snus is advertised as an alternative to cigarettes for use in situations in which smoking is prohibited or restricted to selected areas. Advertising for snus claims “no smoke, no guilt, no blame.” 105 Other slogans that emphasize the fact that no spitting is necessary include phrases such as “backstage-friendly,” “extra-innings friendly,” “club-friendly,” and “work-friendly.” 106 prompt children to ingest these products and is a matter of concern. 109 These novel forms of smokeless tobacco are likely to change the tobacco use profile in the United States. Potential negative outcomes could include: ● Increased youth access to smokeless tobacco products. ● Increased efforts by smokeless tobacco manufacturers to encourage adult cigarette smokers to switch to smokeless tobacco. ● Increased nicotine addiction due to dual use of smokeless and combusted tobacco products. ● Increased youth experimentation with smokeless tobacco. ● Decreased cessation rates as smokers use smokeless tobacco products in smoke-free environments. 82 Dental and Craniofacial Research, a branch of the National Institutes of Health, launched an initiative to encourage studies concerning the effects of e-cigarettes on oral and periodontal epithelial cells. 110 E-cigarettes are increasingly popular with adolescents and part of the reason is false health claims by e-cigeratte manufacturers.
INTERVENTIONS FOR SMOKELESS TOBACCO USE AND DEPENDENCE
the degree of withdrawal depends not only on the amount the individual uses per day, but also the nicotine content of the brand of smokeless tobacco he or she uses. The brands capable of delivering a large dose of nicotine are generally associated with more severe withdrawal symptoms and more challenging quit attempts. Assessing nicotine dependence in smokeless tobacco users continues to be problematic due to the variation in nicotine delivery across products and the absence of guidelines specific to smokeless tobacco cessation. Researchers described a scale that can be useful in assessing nicotine dependence in smokeless tobacco users, which mitigates some of the difficulty associated with rating smokeless tobacco brand nicotine content. The strongest measures of high nicotine dependence are related to the following behaviors: ● Using ST within 30 minutes of awakening. ● Intentionally swallowing the juice. ● Difficulty giving up use in the morning. ● More frequent use during the first hours of the day. 112
The same behavioral interventions described earlier are applicable to smokeless tobacco intervention: the Five A’s, Five R’s, and motivational interviewing. However, there are numerous challenges to fostering smokeless tobacco cessation in a clinical practice setting. Smokeless tobacco users may perceive that they are not nicotine dependent and are at no risk or at a reduced risk of developing tobacco-related diseases. They also believe that periodic situational use poses no health risks. Furthermore, the route of nicotine delivery and plasma nicotine level is significantly different for smokeless tobacco compared to cigarettes. The wide variability in nicotine content across brands makes it challenging to select the appropriate dosage of the nicotine replacement products, which were specifically developed for smoking cessation. In the absence of national guidelines for the use of pharmacotherapy for smokeless tobacco cessation, the clinician must rely on interpretation of the available literature in the practice of smokeless tobacco cessation. Nicotine withdrawal symptoms from smokeless tobacco use are similar to those associated with quitting smoking, but
SMOKELESS TOBACCO CESSATION PHARMACOTHERAPY
● No effect on abstinence from smokeless tobacco was detected with the use of bupropion when compared to the use of an inactive drug (placebo). ● There is no evidence of differences between various types of NRT on abstinence. Failure to demonstrate increased long-term (6 months or longer) smokeless tobacco abstinence in clinical trials may relate to underreplacement of nicotine with standard NRT dosing.
According to the 2008 update of the clinical practice guideline Treating Tobacco Use and Dependence, sufficient evidence-based studies are not yet available to make definitive recommendations on the use of pharmacotherapy for smokeless tobacco cessation. 113 However, preliminary studies have reported some success. A 2011 Cochrane Review offered these conclusions:
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