SAA Webinar--Non-Traditional Tobacco Products by Oral Health America

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

Smokeless Tobacco

SNUS

Cigarette, Cigar, Cigarillo, or Little Cigar?

Sweet Cigarillos

Bidis and Kreteks

Bidis

Kreteks

Electronic Cigarettes

Hookahs

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

“Traditional” Types of Smokeless Tobacco

Smokeless Tobacco Lesions

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

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

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

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

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

The “Swedish Experience”

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

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

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

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

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

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

Percent Who Tried to Quit Smoking

41.2

40 35 30

31.1 27.9

29.6

20 15 10 5 0 Daily Snuff User

Some day Snuff User

Former Snuff User

Never Used Snuff

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

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*

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

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

E-Cigarette Ever Use Among US Middle and High School Students

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

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

10.3

10.5

8.8 7.3Females 7.2

8 6.2

6.2

2009

2010

6 4 2

0 2011

2012

2013

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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