SAA Webinar--Non-Traditional Tobacco Products

ORAL HEALTH AMERICA

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

August 26, 2014

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Repaving Tobacco Road: Emerging Tobacco Products and their Implications for Oral Health Scott L. Tomar, DMD, DrPH University of Florida stomar@dental.ufl.edu Sharee Clough, RDH, MS Ed American Dental Association cloughs@ada.org

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

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Smokeless Tobacco

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SNUS

Š 2014 American Dental Association, All Rights Reserved

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Cigarette, Cigar, Cigarillo, or Little Cigar?

Š 2014 American Dental Association, All Rights Reserved

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Š 2014 American Dental Association, All Rights Reserved

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Sweet Cigarillos

Š 2014 American Dental Association, All Rights Reserved

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Bidis and Kreteks

Bidis

Kreteks

Š 2014 American Dental Association, All Rights Reserved

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Electronic Cigarettes

Š 2014 American Dental Association, All Rights Reserved

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Hookahs

http://http://www.captain-hookah.com/?page_id=2 Š 2014 American Dental Association, All Rights Reserved

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Dissolvables

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 © 2014 American Dental Association, All Rights Reserved

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“Traditional” Types of Smokeless Tobacco

Smokeless Tobacco Lesions

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Percent

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

by Duration of Use 45 40 35 30 25 20 15 10 5 0

38.3

22.9

8.4 1.9 <1 mo.

1-12 mo.

13-24 mo.

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

>24 mo.

Gingival Recession

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

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Š 2014 American Dental Association, All Rights Reserved

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US Airways Magazine. November 2011

Images courtesy of Trinketsandtrash.com

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

 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 3yr-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

© 2014 American Dental Association, All Rights Reserved

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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 people Carpenter 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

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Sales of Smokeless Tobacco United States, 1986-2011

Billions of Dollars

$3.0 $2.5 $2.0

Moist snuff

$1.5

Scotch/Dry Snuff

$1.0

Loose Leaf Chewing Tobacco

$0.5

Snus

$0.0 1986 1990 1994 1998 2002 2006 2010

Federal Trade Commission Report to Congress, 2013 Š 2014 American Dental Association, All Rights Reserved

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Current Use of Cigarettes or ST among Male High School Seniors US Monitoring the Future Project, 1992-2013

40 35

Cigarettes

Percent

30 25 20

Smokeless Tobacco

15 10 5 0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Year Johnston, Oâ&#x20AC;&#x2122;Malley, Bachman, & Schulenberg (2013)

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

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The “Swedish Experience”

Foulds et al. Tobacco Control 2003;12(4):349-59. © 2014 American Dental Association, All Rights Reserved

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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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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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Prevalence of Current Smoking among Daily ST Users 80

Percent Who Smoke

70 60 50 Less than daily smoking Daily smoking

40 30 20 10 0 Middle school High school

Adults

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9. Š 2014 American Dental Association, All Rights Reserved

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Prevalence of Current Smoking among NonDaily ST Users 70

Percent Who Smoke

60 50 40

Less than daily smoking Daily smoking

30 20 10 0 Middle school High school

Adults

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9. Š 2014 American Dental Association, All Rights Reserved

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

Percent Considering Quitting

60 48.0

50 40

44.8 39.2

36.5

30 20 10 0 Daily Snuff User

Some day Snuff User

Tomar, Alpert, Connolly. Tobacco Control

Former Snuff User 2010; 19:104-9.

Never Used Snuff

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

Percent Who Tried to Quit Smoking

45

41.2

40 35 30

31.1 27.9

29.6

25

20 15 10 5 0 Daily Snuff User

Some day Snuff User

Former Snuff User

Never Used Snuff

Tomar, Alpert, Connolly. Tobacco Control 2010; 19:104-9. Š 2014 American Dental Association, All Rights Reserved

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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

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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

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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

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E-Cigs Projected to be $3 Billion Market by 2015

http://www.businessinsider.com/e-cigarettes-will-be-3-billion-market-2013-5 Š 2014 American Dental Association, All Rights Reserved

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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 Š 2014 American Dental Association, All Rights Reserved

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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

Current Hookah Smoking

by U.S. High School Students National Youth Tobacco Surveys 2011 & 2012 7

Percent Current Hookah Smoking

6.2 6 5 4 3

4.5

3.5

4.8

2011 2012

2 1 0

Boys CDC. MMWR 2013;62:893-7.Girls http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm?s_cid=%20mm6245a2.htm_w Š 2014 American Dental Association, All Rights Reserved

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Current Hookah Smoking by U.S. Undergraduate College Students, National College Health Assessments, 2009-2013 14

Percent Current Hookah Smoking

12.3 12

Males

10.1

10.1

10.3

10.5

10

8.8 7.3Females 7.2

8 6.2

6.2

2009

2010

6 4 2

0 2011

2012

2013

American College Health Association. http://www.acha-ncha.org/reports_ACHA-NCHAII.html Š 2014 American Dental Association, All Rights Reserved

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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 ecigarettes 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 © 2014 American Dental Association, All Rights Reserved

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Thank You!