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ORAL HEALTH AMERICA Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral Health August 26, 2014

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Page 1: SAA Webinar--Non-Traditional Tobacco Products

ORAL HEALTH AMERICA

Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral

Health

August 26, 2014

Page 2: SAA Webinar--Non-Traditional Tobacco Products

/Oral Health America @Smile4Health

Connect with OHA!

Page 3: SAA Webinar--Non-Traditional Tobacco Products

HOUSEKEEPING INFORMATION

• Please remember to MUTE your line by pressing *6 on your phone.

• Questions are welcome! We’ll allow 10-15 minutes after the presentation for questions.

• Questions will be accepted in writing through the control panel on the upper right hand of your screen.

• Submit questions at any time; we will address them at the end of the presentation.

• Webinar is being recorded; for rebroadcast on OHA’s website –OralHealthAmerica.org

• Your feedback is important to us. Please take our brief webinar evaluation after this session; link will be sent via email.

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Oral Health America changes lives by connecting communities with

resources to increase access to care, education, and advocacy for

all Americans,

especially those most vulnerable.

OUR MISSION

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OHA PRIORITIESOur Programs and Campaigns must have the capacity –short term or longer term – to influence health literacy, improve access to services and to advocate for systemic changes that will impact the oral and overall health of all Americans – particularly those most vulnerable.

ACCESS EDUCATION

ADVOCACY

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Grant Funding

Sealant Initiative

Product Donation

Technical Assistance

Supportive Research

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Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral Health

Scott L. Tomar, DMD, DrPH

University of Florida

[email protected]

Sharee Clough, RDH, MS Ed

American Dental Association

[email protected]

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© 2014 American Dental Association, All Rights Reserved 9

Outline

•New and emerging tobacco products

•“Harm reduction” and new products

•Big Tobacco and new products

• Implications for oral health and overall health

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© 2014 American Dental Association, All Rights Reserved 11

SNUS

Page 13: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 13

Page 14: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 14

Sweet Cigarillos

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© 2014 American Dental Association, All Rights Reserved 15

Bidis and Kreteks

Bidis Kreteks

Page 17: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 17

Hookahs

http://http://www.captain-hookah.com/?page_id=2

Page 18: SAA Webinar--Non-Traditional Tobacco Products

Dissolvables

Page 19: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 19

Adverse Health Effects of ST Use

• Oral and pharyngeal cancer

• Pancreatic cancer

• Smokeless tobacco keratosis / leukoplakia

• Gingival recession

• Dental caries (chewing tobacco)

• Cardiovascular diseases

• Type 2 diabetes and insulin resistance (?)

• Reproductive health effects

• Nicotine addiction

Page 20: SAA Webinar--Non-Traditional Tobacco Products

“Traditional” Types of Smokeless Tobacco

Page 21: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 21

Smokeless Tobacco Lesions

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Prevalence of ST Lesions Among Snuff Users Age 12-17 Years, by Duration of Use

1.9

8.4

22.9

38.3

0

5

10

15

20

25

30

35

40

45

<1 mo. 1-12 mo. 13-24 mo. >24 mo.

Perc

en

t

Duration of Use

Source: Tomar et al. J Dent Res 1997; 76:1277-86.

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Gingival Recession

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© 2014 American Dental Association, All Rights Reserved 25

Recent Developments in U.S.

Smokeless Tobacco (ST) Industry

Until 2006, most ST in the U.S. made by companies that did not sell cigarettes

2006: Reynolds American acquires Conwood Co.

2008: Altria acquires US Smokeless Tobacco Co.

2008: Lorillard joint venture with Swedish Match

2008: Liggett introduces Grand Prix Snus

2009: PMI joint venture with Swedish Match

2010: Nearly entire U.S. ST industry controlled by cigarette companies

Page 26: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 26

Page 27: SAA Webinar--Non-Traditional Tobacco Products

US Airways Magazine. November 2011

Page 28: SAA Webinar--Non-Traditional Tobacco Products

Images courtesy of

Trinketsandtrash.com

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© 2014 American Dental Association, All Rights Reserved 30

13,705 cases of accidental poisoning from ingestion of tobacco products by children <6 yrs old, 2006-2008

>70% by infants <1

At least 1 case of poisoning by ingestion of Orbs by 3-yr-old

Orbs contain 1 mg nicotine, pH 7.8

Estimated lethal dose: 1.0 mg nicotine/kg body weight

16-27 Orbs probably fatal dose for 4-year-old

Connolly et al. Pediatrics 2010;125:896-9.

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© 2014 American Dental Association, All Rights Reserved 31

Tobacco Industry Strategies

• Promote dual use of ST and

cigarettes

• Undermine effectiveness of

smokefree ordinances in

reducing smoking

• Diversified products under

prospect of federal regulation

• Continue aggressive

promotion to young peopleCarpenter et al. Developing smokeless tobacco products for

smokers: an examination of tobacco industry documents. Tob Control 2009;18(1):54-9.

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© 2014 American Dental Association, All Rights Reserved 32

Sales of Smokeless Tobacco United States, 1986-2011

$0.0

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

1986 1990 1994 1998 2002 2006 2010

Bill

ion

s o

f D

olla

rs

Moist snuff

Scotch/Dry Snuff

Loose Leaf ChewingTobacco

Snus

Federal Trade Commission Report to Congress, 2013

Page 33: SAA Webinar--Non-Traditional Tobacco Products

Current Use of Cigarettes or ST among

Male High School SeniorsUS Monitoring the Future Project, 1992-2013

0

5

10

15

20

25

30

35

40

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Perc

en

t

Year

Johnston, O’Malley, Bachman, & Schulenberg (2013)

Cigarettes

Smokeless Tobacco

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© 2014 American Dental Association, All Rights Reserved 34

ST and Tobacco Harm Reduction:

The Theory

• Exclusive use of ST products carries lower

risk for death and disease than smoking

• Smokers unable or unwilling to quit could

reduce risks by switching to ST

• The decline in smoking by Swedish men was

largely due to switch to snus

Page 35: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 35

The “Swedish Experience”

Foulds et al. Tobacco Control 2003;12(4):349-59.

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© 2014 American Dental Association, All Rights Reserved 36

ST and Tobacco Harm Reduction:

The Reality

• Little evidence for snus as effective smoking

cessation strategy

• Smoking in Sweden declined among women

despite very low use of snus

• Smoking now lower for women than men <35

• Harm associated with product is function of

how it is used, not just its composition

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© 2014 American Dental Association, All Rights Reserved 37

Concerns about Cigarette Company Control

of ST Market

• Promote dual use/situational substitute

• Deferred smoking cessation

• Dual use and dual addiction

• Increased ST initiation by young people

• Potential for either reduction or increase of

public health harm

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© 2014 American Dental Association, All Rights Reserved 38

Prevalence of Current Smoking among Daily ST Users

0

10

20

30

40

50

60

70

80

Middle school High school Adults

Perc

en

t W

ho

Sm

oke

Less than dailysmoking

Daily smoking

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9.

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© 2014 American Dental Association, All Rights Reserved 39

Prevalence of Current Smoking among Non-Daily ST Users

0

10

20

30

40

50

60

70

Middle school High school Adults

Perc

en

t W

ho

Sm

oke

Less than dailysmoking

Daily smoking

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9.

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© 2014 American Dental Association, All Rights Reserved 40

Seriously Considering Quitting Smoking Within Next 6 Months, Male Daily Smokers, by Snuff Use Status

36.5

48.044.8

39.2

0

10

20

30

40

50

60

Daily SnuffUser

Some daySnuff User

Former SnuffUser

Never UsedSnuff

Perc

en

t C

on

sid

eri

ng

Qu

itti

ng

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9.

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© 2014 American Dental Association, All Rights Reserved 41

Quit Smoking for 1+ Days in Past 12 Months, Male Daily Smokers, by Snuff Use Status

27.9

41.2

31.129.6

0

5

10

15

20

25

30

35

40

45

Daily SnuffUser

Some daySnuff User

Former SnuffUser

Never UsedSnuff

Perc

en

t W

ho

Tri

ed

to

Qu

it

Sm

okin

g

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9.

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© 2014 American Dental Association, All Rights Reserved 42

Electronic Cigarettes (E-cigarettes)

Vaporized nicotine

At least 25 different manufacturers

Little data on constituents of vapor

No data on efficacy for smoking cessation

Controversy over use in smoke-free areas

Feb 2010, US District Court ruled FDA lacked authority to

regulate e-cigs as drug-delivery device

Regulated by FDA as tobacco product

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© 2014 American Dental Association, All Rights Reserved 43

E-Cigarettes

• FDA testing of several brands found:

– Diethylene glycol

– Tobacco-specific nitrosamines

– Tobacco-specific impurities

– Inconsistent nicotine dosing

• Recent report of lipoid pneumonia in e-cig smoker*

http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf

*McCauley et al. Chest 2012;141(4):1110-3

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© 2014 American Dental Association, All Rights Reserved 44

Big Tobacco enters the e-cigarette market

• Altria Group (Marlboro):

MarkTen launched nationally

Q2 2014

• Lorillard (Newport): acquired

Blu in 2012; SKYCIG in 2013

• Reynolds American (Camel):

launched VUSE June 2013

Page 45: SAA Webinar--Non-Traditional Tobacco Products

© 2014 American Dental Association, All Rights Reserved 45

E-Cigs Projected to be $3 Billion Market

by 2015

http://www.businessinsider.com/e-cigarettes-will-be-3-billion-market-2013-5

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© 2014 American Dental Association, All Rights Reserved 46

E-Cigarette Ever Use Among US

Middle and High School Students

CDC. MMWR 2013; 62(35):729-30 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm

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Hookah (Waterpipe)

Maziak W. Cancer Epidemiol 2013;37:1-4

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Health Effects of Hookah Smoking

• High levels of CO & toxins

• Increased risk of: – Lung cancer

– Respiratory illness

– Low birth weight

– Periodontitis

– Post-extraction dry socket

• Probable increased risk for oral cancer

• Possible transmission of infectious agents

Akl et al. Int J Epidemiol 2010; 39: 834–57; Maziak W. Cancer Epidemiol 2013;37:1-4

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© 2014 American Dental Association, All Rights Reserved 49

Current Hookah Smoking by U.S. High School StudentsNational Youth Tobacco Surveys 2011 & 2012

3.5

4.84.5

6.2

0

1

2

3

4

5

6

7

Girls Boys

Perc

en

t C

urr

en

t H

oo

kah

S

mo

kin

g

2011

2012

CDC. MMWR 2013;62:893-7.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm?s_cid=%20mm6245a2.htm_w

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© 2014 American Dental Association, All Rights Reserved 50

Current Hookah Smoking by U.S. Undergraduate College Students, National College Health Assessments,

2009-2013

6.2 6.2

7.3 7.2

8.8

10.1 10.1 10.3 10.5

12.3

0

2

4

6

8

10

12

14

2009 2010 2011 2012 2013

Perc

en

t C

urr

en

t H

oo

kah

S

mo

kin

g

Males

Females

American College Health Association. http://www.acha-ncha.org/reports_ACHA-NCHAII.html

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© 2014 American Dental Association, All Rights Reserved 51

Summary

• All forms of tobacco use have known or probable adverse effects on general health and oral health

• Tobacco landscape is changing rapidly

• New (and old) smokeless tobacco products and e-

cigarettes being heavily promoted

• Weak evidence base for non-cigarette tobacco

products as effective method to quit smoking

• Net harm to individual and population depends how

product is used

• Likely to be intense debate around product regulation

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Thank You!