Smokeless Tobacco Cessation: Review of the evidence. Raymond Boyle, PhD Tobacco Summit 2007 MDQuit.org
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1 Smokeless Tobacco Cessation: Review of the evidence Raymond Boyle, PhD Tobacco Summit 2007 MDQuit.org
2 Previous Reviews of ST evidence Hatsukami and Boyle (1997) Evidence base is limited by small sample sizes and lack of control groups Ebbert et al. (2007) A Cochrane review Behavioural treatments may help people stop using ST
3 Presentation Goals To review the current status of ST use in the United States To review the behavioral and pharmacologic evidence for ST cessation To discuss the debate of ST as a method for smoking cessation
4 Smokeless Tobacco (ST) Products
5 Sales of Smokeless Tobacco in Dollars United States, Billions of Dollars $1.8 $1.6 $1.4 $1.2 $1.0 $0.8 $0.6 $0.4 $0.2 $ Moist snuff Loose Leaf Chewing Tobacco Source: FTC Report to Congress, 2001
6 Adverse Health Effects of ST Use Oral and pharyngeal cancer Smokeless tobacco keratosis / leukoplakia Gingival recession Dental caries Cardiovascular diseases Nicotine addiction
7 Current ST Use by Males Aged 18+ Yrs BRFSS, >10% 7-10% <7% Data unavailable
8 Nicotine plasma concentrations, HR, and subjective ratings of drug strength Fant, R. V et al. Tob Control 1999;8: Copyright 1999 BMJ Publishing Group Ltd.
9 Pharmacotherapy for ST Use: What is Known
10 Goals of Pharmacotherapy Increase abstinence (quit rates) Control symptoms Craving Withdrawal
11 Medications Tried for ST Use Nicotine gum Nicotine patch Bupropion SR Nicotine lozenge
12 Efficacy Ebbert. Cochrane Database Syst Rev, 2007
13 Symptom Control: Craving & Withdrawal Nicotine gum (2 mg/d) Reduces craving A Reduces withdrawal symptoms A Nicotine patch (21 mg/d) Reduces craving B Reduces withdrawal symptoms B A Hatsukami et al. J Consult Clin Psychol. Feb 1996;64(1): B Hatsukami et al. J. Consult. Clin. Psychol. 2000;68(2):
14 Medications Tried for ST Use Nicotine gum Nicotine patch Bupropion SR Nicotine lozenge
15 Efficacy Ebbert. Cochrane Database Syst Rev, 2007
16 Desire to Use Tobacco 4 Mean score (desire) * * * Bupropion Placebo * * * *P 0.05 comparing groups Day following TQD Dale et al. Drug Alcohol Depend CP
17 Mean weight change (kg) Weight Change During Medication Phase Start of med Bupropion Placebo *P 0.05 bupropion compared to placebo * * * * TQD End of med Week * * Dale et al. Drug Alcohol Depend CP
18 7-Day Point Prevalence Abstinence Abstinent (%) Bupropion Placebo 0 Start of med TQD End of med Week Dale et al. Drug Alcohol Depend CP
19 Bupropion SR Study Conclusions Bupropion SR is effective for: Decreasing craving Attenuating weight gain Bupropion SR is not effective for: Increasing long-term ST abstinence rates Decreasing withdrawal symptoms
20 Nicotine Lozenges for ST Users
21 Nicotine Lozenge Study Goal lozenges/day Max lozenges/day Weeks Weeks Weeks Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
22 Nicotine Lozenge Study ST users: 18 years of age Daily use for the 6 months 4 mg nicotine lozenge 30 subjects Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
23 Nicotine Lozenge Study Conclusions Nicotine lozenge may be effective for addressing: Craving Withdrawal Conclusions must be interpreted with caution About 47% quit Placebo-controlled study is ongoing Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
24 ST Behavioral interventions randomized by organization
25 ST behavioral interventions randomized by individual Ebbert. Cochrane Database Syst Rev, 2007
26 ST Behavioral Interventions: Evidence Summary The Cochrane review identified 8 RCTs Positive, strong effects are seen for Telephone counseling Dental team advice Self-help materials (web, video, manual) Interventions with athletic teams
27 Recommended Treatment Approach 1. Behavioral treatment Oral examination Oral replacement products Reducing/blending Telephone based CBT 2. Consider tailored nicotine therapy Patch/gum/lozenge for self-titration
28 The ST harm reduction debate A product is harm reducing if it lowers total tobacco-related mortality and morbidity even though continued use may involve exposure to tobacco toxins (Stratton et al. 2001) Brad Rodu, DDS 1992 TSNAs Snus vs. Snuff
29 Cigarette companies enter the market
30 Contact Raymond Boyle Telephone: Mayo Clinic College of Medicine. All Rights Reserved.
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