saa webinar--non-traditional tobacco products
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ORAL HEALTH AMERICA
Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral
Health
August 26, 2014
/Oral Health America @Smile4Health
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Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral Health
Scott L. Tomar, DMD, DrPH
University of Florida
Sharee Clough, RDH, MS Ed
American Dental Association
© 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
© 2014 American Dental Association, All Rights Reserved 10
Smokeless Tobacco
© 2014 American Dental Association, All Rights Reserved 11
SNUS
© 2014 American Dental Association, All Rights Reserved 12
Cigarette, Cigar, Cigarillo, or Little Cigar?
© 2014 American Dental Association, All Rights Reserved 13
© 2014 American Dental Association, All Rights Reserved 14
Sweet Cigarillos
© 2014 American Dental Association, All Rights Reserved 15
Bidis and Kreteks
Bidis Kreteks
© 2014 American Dental Association, All Rights Reserved 16
Electronic Cigarettes
© 2014 American Dental Association, All Rights Reserved 17
Hookahs
http://http://www.captain-hookah.com/?page_id=2
Dissolvables
© 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
“Traditional” Types of Smokeless Tobacco
© 2014 American Dental Association, All Rights Reserved 21
Smokeless Tobacco Lesions
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.
Gingival Recession
© 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
© 2014 American Dental Association, All Rights Reserved 26
US Airways Magazine. November 2011
Images courtesy of
Trinketsandtrash.com
© 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.
© 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.
© 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
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
© 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
© 2014 American Dental Association, All Rights Reserved 35
The “Swedish Experience”
Foulds et al. Tobacco Control 2003;12(4):349-59.
© 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
© 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
© 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.
© 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.
© 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.
© 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.
© 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
© 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
© 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
© 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
© 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
Hookah (Waterpipe)
Maziak W. Cancer Epidemiol 2013;37:1-4
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
© 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
© 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
© 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
Thank You!