This course was published in the February 2019 issue and expires February 2022. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Identify common types of smokeless tobacco products.
- Discuss the perceived benefits and misconceptions associated with smokeless tobacco products.
- List the oral and systemic effects of smokeless tobacco use.
- Explain the overall trends of tobacco use in the United States.
- Describe the recommended methods of tobacco cessation.
Tobacco use is a worldwide epidemic and the leading cause of death, illness, and impoverishment. It poses one of the largest threats to public health the world has ever faced.1 In the United States, the prevalence of cigarette smoking among adults has been on a gradual decline for decades, but it remains the most commonly used form of tobacco.1 In comparison, the prevalence of smokeless tobacco use is approximately one-fourth that of cigarettes; however, it has experienced an overall increase since the year 2000.1 Reasons for these concurrent trends include marketing strategies of the tobacco industry and legislative actions. Targeting any single form of tobacco use, such as cigarette smoking, will impact the use of alternative tobacco products (ATP), such as smokeless tobacco. Furthermore, the use of any form of tobacco is harmful.
In particular, smokeless tobacco products increase the risk of developing certain cancers associated with high morbidity and mortality rates.2 While many public health coalitions have a primary focus on “quit smoking” campaigns, the detrimental oral and systemic effects of smokeless tobacco use cannot be ignored. Incorporating a discussion of smokeless tobacco will create a more comprehensive approach to health promotion efforts. Oral health professionals must not only assess patients for all types of tobacco use, but also carefully consider cessation strategies and assist the patient in creating an individualized tobacco cessation program.3
PERCEIVED BENEFITS AND RISKS OF TOBACCO USE
Despite an abundance of information about cigarette smoking, there is comparatively little published about smokeless tobacco products and those who use them. The most common types of smokeless tobacco in the US are chewing tobacco and snuff.4 Chewing tobacco, also called spit tobacco, generally comes in the form of loose leaves, twists, or plugs of dried tobacco and may be flavored.4 It is usually chewed or placed in the lower buccal or labial vestibule of the mouth and sucked on while spitting out the juices. Snuff, referred to as dipping tobacco or dip, is available moist or dry and may have added flavoring. Moist snuff may also be called snus. Similarly, this product is placed in the buccal or labial vestibule as a pinch of loose tobacco or as a pouch. Dry snuff comes in a fine powder form and may be inhaled nasally rather than consumed orally.4
In 2009, a dissolvable compressed tobacco product was introduced in the US by a major tobacco company. Dissolvable tobacco comes in lozenges, strips, or sticks, and does not require spitting or disposing of the product. As with the other forms of smokeless tobacco, the dissolvable products contain nicotine and carcinogens.5 The Federal Trade Commission Smokeless Tobacco Report for 2015 reported that moist snuff sales have risen every year since 1987 and now surpass the combined sales of all other forms of smokeless tobacco.6
The perceived physiologic benefits of any tobacco use include providing a sense of well-being, decreasing anxiety, reducing depression, and aiding in focused attention. In reality, however, the physiologic threat is that nicotine affects mood, creates dependence, and causes withdrawal symptoms during cessation attempts.7 It is difficult to quit spit tobacco because smokeless tobacco products contain higher nicotine levels compared with cigarettes.8 Although the amount of nicotine in smokeless tobacco products varies widely between brands and type,9 one dip/chew can deliver up to five times the amount of nicotine found in one cigarette. In fact, one can of dip or snuff is equivalent to 80 cigarettes.8 Finally, smokeless tobacco can be used in locations where smoking is not permitted.
Smokeless tobacco use poses significant health risks. There is a common misconception that smokeless tobacco products are a safe substitute for smoking cigarettes. In fact, smokeless tobacco contains 28 different carcinogens, and individuals who use smokeless tobacco products have an increased risk for oral, esophageal, and pancreatic cancers.10 Smokeless tobacco use can lead to nicotine addiction and dependence as well as other serious health conditions, such as cardiovascular disease, high blood pressure, and stroke. In addition, smokeless tobacco products cause many adverse oral health conditions, such as oral malodor, dental caries, tooth abrasion, gingival recession, periodontal disease, leukoplakia, and oral and pharyngeal cancer.11 Currently, the incidence of oral cancer makes up approximately 3% of all cancers in the US and causes 1.6% of all cancer-related deaths.12 While the percentage of oral cancer incidence is relatively small when compared with other cancers, the 5-year survival rate for oral cancer (64%) is far less than breast (90%) or bladder cancer (77%).12 Furthermore, the use of smokeless tobacco by women has been associated with premature birth and low birth-weight babies, ectopic pregnancies, orofacial clefts, and stillbirths.10
TRENDS IN SMOKELESS TOBACCO USE
The use of smokeless tobacco products is highest among American Indians/Alaska Natives (7.1%) followed by non-Hispanic whites (4.6%).13 A 2017 study found that the use of smokeless tobacco was most commonly associated with men younger than 60 who possess less than a college degree, earn at least $25,000 but less than $50,000 annually, and live in the Midwestern or Western US.14
According to Behavioral Risk Surveillance System data, the four states with the highest rate of smokeless tobacco use are Wyoming, West Virginia, Montana, and Mississippi. Interestingly, Jones, et al14 suggest that smokeless tobacco trends may be changing in the US. They noted that while users are generally young, white men who are less educated, there is now no significant relationship to geographic region, income, and race/ethnicity, as in the past. When comparing 2014 to 2016, the association between being male and using smokeless tobacco products was considerably less. Likewise, data on race/ethnicity revealed higher use among non-Hispanic blacks than previously reported. This may be the result of tobacco companies targeting their marketing efforts to a more diverse population.14 Due to the decline in cigarette smoking, tobacco companies have expanded their smokeless tobacco product lines and, in 2015, manufacturers invested approximately $685 million dollars in creative marketing strategies to attract other users, including non-Hispanic blacks and women.14
The age of initiation is an important aspect of the demographic characteristics of smokeless tobacco product use. It is estimated that in 2014, approximately 1 million individuals age 12 and older began using smokeless tobacco.15 Those who initiated use were generally young men aged 18 to 25. The next highest group was adolescents aged 12 to 17.15 Research also shows that the tobacco industry consistently and heavily markets lower nicotine, flavored brands of smokeless tobacco products to young, inexperienced users.16 Young users often associate flavored and sweetened products as more palatable, easier to use, and less harmful. These products are sometimes referred to as “starter products,” as the first step of the tobacco industry’s campaign to advance young users to more potent nicotine products.16,17
Pouched tobacco is also heavily marketed to adolescents and other beginner users of smokeless tobacco products. Advertised as a cleaner, more hygienic, and more convenient product, pouched tobacco has regained popularity as a socially acceptable alternative to smoking cigarettes.16 Currently, every major US tobacco company offers a pouched tobacco product. The ease of use and lower nicotine levels of pouched tobacco is a selling point among younger and beginner smokeless tobacco product users.16
Hawkins et al18 reported that an increase in state cigarette taxes and the passage of smoke-free legislation in recent years have been associated with an increase in the use of smokeless tobacco products in young men. Due to higher cigarette taxes, adolescent males have looked for cheaper ways to use tobacco products. Dual tobacco use (the use of two tobacco products) or poly-tobacco use (the use of three or more tobacco products) is a rising trend among those aged 18 to 25.2 The frequency and length of use are directly related to the risk of and extent of adverse health consequences. Therefore, it is extremely important to consider the age of initiation for the development of prevention and cessation strategies.
Smokeless tobacco use is not safe and tobacco users need help to quit. The US Centers for Disease Control and Prevention’s Best Practices for Comprehensive Tobacco Control Programs state the importance of insurance coverage and utilization of proven, comprehensive cessation treatments.19 This means that health benefits should include coverage for individual, group, and telephone counseling, as well as all seven US Food and Drug Administration-approved cessation medications. These are: bupropion; varenicline; and nicotine replacement patches, gums, lozenges, inhalers, and nasal sprays. Some insurance plans will cover the cost of selected aspects of tobacco cessation. Therefore, it is important that the insured and health care providers are aware of the coverage that exists for the patient, which could increase the chances that the benefits will be used.19
The World Health Organization’s (WHO) Monograph on Tobacco Cessation and Oral Health Integration describes the unique role of oral health professionals in helping tobacco users. The data show that greater than 60% of tobacco users see their dentist or dental hygienist annually in developed countries. Oral health professionals are concerned about the adverse oropharyngeal effects of tobacco use and can demonstrate to the patient any physical changes in the mouth. These characteristics make oral health professionals uniquely qualified to implement tobacco cessation education.
Oral health professionals also have access to key populations such as vulnerable youth, parents/caregivers, and women of childbearing age. This facilitates both prevention and cessation interventions. Oral health professionals have also been shown to be as effective as other health professionals in helping tobacco users quit. For these reasons, the WHO recommends that routine primary care services by oral health professionals should deliver at least a brief tobacco intervention. In fact, there is evidence that brief behavioral counseling at an oral care appointment combined with an oral examination can increase tobacco abstinence rates by 70%.20
There are two common models that can quickly and easily be incorporated into a dental appointment. The first is known as the “5 As” which stands for ask, advise, assess, assist, and arrange.20 The first step “Ask” refers not only to identifying all tobacco users but also refers to discussing their patterns of use in order to differentiate smokers from users of spit tobacco. This should be documented and kept up-to-date. The second step “Advise” emphasizes the importance of a direct recommendation of tobacco cessation by a health professional. Third, “Assess” determines a patient’s readiness to make a quit attempt. If the patient is prepared to quit, the oral health professional can move ahead to the fourth step, “Assist” and encourage the patient to develop a quit plan. The final step is to “Arrange” a follow-up visit or phone call during the first week following the quit date and a second contact 1 month later.20
The second model is known as the “5 Rs.” These are: “relevance” to the patient; “risks” of tobacco use; “rewards” of cessation; “roadblocks” to cessation; and “repetition” of information. This model is intended to increase motivation for patients who are not ready to quit. Discussion of the risks and rewards is most useful if the patient does not express a desire to be a nontobacco user, whereas a focus on the roadblocks addresses patients who want to stop using tobacco products, but express a lack of confidence in their ability to quit. If patients are still not ready to quit, end with a positive message and an invitation to return if they change their minds in the future. Implementing the 5 As and 5 Rs is estimated to take 3 minutes to 5 minutes of appointment time.20
Useful resources include quit lines and websites for tobacco cessation. Dialing 1-800- QUIT-NOW will connect automatically to the state’s quit line. The National Cancer Institute also has trained counselors available in English or Spanish at 1-877-448-QUIT. Two reputable websites are smokefree.gov and quitnet.com. Numerous apps are available for tobacco cessation, although no literature supports a specific recommendation. Other emerging technologies include text messaging and social media interventions. These formats may appeal to tobacco users because of convenience and because these formats are familiar to young adults.19
Although oral health professionals are uniquely positioned to perform tobacco cessation, more than 40% do not routinely ask patients about tobacco use and 60% do not routinely advise tobacco users to quit.20 The major barrier is a lack of tobacco cessation training during formative education. This results in a lack of confidence regarding knowledge of ATP use and readiness to assume tobacco intervention roles by both students and practitioners. It is clear that tobacco cessation programs must be conducted by oral health professionals. In order to accomplish this goal, tobacco dependence prevention and cessation should be integral to dental and dental hygiene education and clinical training. Furthermore, continuing education seminars must be developed for existing practitioners. Content for both students and licensed professionals should include instruction on brief motivational interviewing, pharmacotherapy, and establishing a tobacco control program in the dental practice.21
Tobacco use is a worldwide epidemic and a public health threat. Regulatory policy must continue to monitor and influence the deceptive marketing strategies of the tobacco industry with strong legislative efforts. A comprehensive approach to prevention and cessation that includes all forms of tobacco is needed for successful programs. Limiting efforts to just “quit smoking” campaigns can actually increase the rates of smokeless tobacco use. Dental and allied dental education programs must incorporate tobacco cessation content to increase the number of graduates who are confident in delivering evidence-based care on this topic. With adequate training oral health professionals can provide an important contribution to solving this public health crisis.
- World Health Organization. Tobacco: Key Facts. Available at: who.int/news-room/fact-sheets/detail/tobacco. Accessed January 23, 2019.
- United States Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Available at: surgeongeneral.gov/library/reports/50-years-of-progress/index.html. Accessed January 23, 2019.
- Couch ET, Chaffee BW, Gansky SA, Walsh, MM. The changing tobacco landscape. J Am Dent Assoc. 2016;147:561–569.
- United States Centers for Disease Control and Prevention. Smokeless Tobacco Products and Marketing. Available at: cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/products_marketing/index.htm. Accessed January 23, 2019.
- United States Food and Drug Administration. Dissolvable Tobacco Products. Available at: .fda.gov/tobaccoproducts/labeling/productsingredientscomponents/ucm482569.htm. Accessed January 23, 2019.
- Federal Trade Commission. Federal Trade Commission Smokeless Tobacco Report for 2015. Available at: ftc.gov/system/files/documents/reports/federal-trade-commission-cigarette-report-2015-federal-trade-commission-smokeless-tobacco-report/2015_smokeless_tobacco_report.pdf. Accessed January 23, 2019.
- Klein H, Sterk CE, Elifson KW. Smoke and mirrors: the perceived benefits of continued tobacco use among current smokers. Health Psychol Res. 2014;2:78–84.
- Oral Health America. National Spit Tobacco Program. Available at: oralhealthamerica.org/wp-content/uploads/What-you-need-to-know.pdf. Accessed January 23, 2019.
- United States Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. 2012. Available at: surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf. Accessed January 23, 2019.
- United States Centers for Disease Control and Prevention. Smokeless Tobacco Health Effects. Available at: cdc.gov/tobacco/data_ statistics/fact_sheets/smokeless/health_effects/index.htm. Accessed January 23, 2019.
- American Cancer Society. Health Risks of Smokeless Tobacco. Available at: cancer.org/cancer/cancer-causes/tobacco-and-cancer/smokeless-tobacco.html. Accessed January 23, 2019.
- National Cancer Institute. Surveillance, Epidemiology and End Results Program. Cancer Stat Facts: Oral Cavity and Pharynx Cancer. Available at: seer.cancer.gov/statfacts/html/oralcav.html. Accessed January 23, 2019.
- United States Centers for Disease Control and Prevention. Smokeless Tobacco Use in the United States. Available at: cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/use_us/index.htm. Accessed January 23, 2019.
- Jones DM, Majeed BA, Weaver SR, Sterling K, Pechacek TF, Eriksen MP. Prevalence and factors associated with smokeless tobacco use 2014-2016. Am J Health Behav. 2017;41:608–617.
- Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The CBHSQ Report: Trends in Smokeless Tobacco Use and Initiation 2002-2014. Available at samhsa.gov/data/node/58298. Accessed January 23, 2019.
- Chaffee BW, Urata J, Couch ET, Gansky SA. Perceived flavored smokeless tobacco ease-of-use and youth susceptibility. Tob Regul Sci. 2017;3:367–373.
- Hendlin YH, Veffer JR, Lewis MJ, Ling PM. Beyond the brotherhood: Skoal Bandits’ role in the evolution of marketing moist smokeless tobacco pouches. Tob Induced Diseases. 2017;15:46.
- Hawkins SS, Bach N, Baum CF. Impact of tobacco control policies on adolescent smokeless tobacco and cigar use: a difference-in-differences approach. BMC Public Health. 2018;18:154.
- United States Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. Available at: cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf. Accessed January 23, 2019.
- World Health Organization WHO Monograph on Tobacco Cessation and Oral Health Integration. Available at: apps.who.int/iris/bitstream/handle/10665/255692/9789241512671eng.pdf;jsessionid=4D9E6E1D4311C4B05E87BD2424AF3822?sequence=1. Accessed January 23, 2019.
- Coan L, Windsor LJ, Romito LM. Increasing tobacco intervention strategies by oral health practitioners in Indiana. J Dent Hyg. 2015;89:190–201.
From Dimensions of Dental Hygiene. February 2019;17(2):40–43.