[Adverse effects of Swedish smokeless tobacco "snus"]

Selling smokeless tobacco (snus) in Finland is illegal, yet one-third of all males aged 16 to 18 years have tried it. A regular snus user can receive a daily dose of 60 to 150 milligrams of nicotine and become heavily addicted. The first--and easily detectable--lesions appear in the oral mucosa and gingiva. Long-time followup studies of snus use from a young age are, however, still lacking. Evidence exists of increased risk for fatal cardiovascular diseases and increased risk for injuries. Risk for oral cancer is debated, with more studies showing an increased risk than showing no risk; risk also exists for cancer of esophagus, stomach and pancreas. A new and alarming finding among female users is increased risk for preterm birth, preeclampsia and neonatal apnea.

Tobacco cessation interventions by Swedish dental hygienists--a questionnaire study

The aim of the study was to investigate tobacco cessation interventions by Swedish dental hygienists and their perception of the importance of tobacco cessation to oral health. A questionnaire was mailed to 400 randomly selected dental hygienists (DH) in Sweden. The questions covered such topics as tobacco cessation interventions, perceived barriers, and their perception of the importance of tobacco cessation in relation to caries, gingivitis, periodontitis and dental implants. The response rate was 57%. Tobacco habits were routinely recorded by 94% of the respondents. 52% of the dental hygienists reported time constraints, 50% reported insufficient competence and 43% answered that they had lack of experience to work with tobacco cessation. All respondents perceived tobacco cessation to be an important determinant of treatment outcomes in patients with dental implants and periodontitis. Bivariate analysis showed an association between training courses in tobacco cessation and tobacco cessation interventions (OR 3.25, CI 95% 1.80-5.85). A logistic multivariate regression model disclosed two other factors significantly correlated with tobacco cessation interventions: competence (OR 2.4, 95% CI 1.16-4.85), and experience (OR 2.1, 95% CI 1.06-4.28). The analyses were adjusted for age, length of undergraduate training course, and dental care organization. The dental hygienists considered tobacco cessation to be very important in patients with periodontitis and in those with dental implants. Most of the DH in this study undertook some tobacco cessation interventions, though not extensive; the main barriers reported were lack of time, competence and experience.

Consensus Report: 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

Role and models for compensation of tobacco use prevention and cessation by oral health professionals

Appropriate compensation of tobacco use prevention and cessation (TUPAC) would give oral health professionals better incentives to provide TUPAC, which is considered part of their professional and ethical responsibility and improves quality of care. Barriers for compensation are that tobacco addiction is not recognised as a chronic disease but rather as a behavioural disorder or merely as a risk factor for other diseases. TUPAC-related compensation should be available to oral health professionals, be in appropriate relation to other dental therapeutic interventions and should not be funded from existing oral health care budgets alone. We recommend modifying existing treatment and billing codes or creating new codes for TUPAC. Furthermore, we suggest a four-staged model for TUPAC compensation. Stages 1 and 2 are basic care, stage 3 is intermediate care and stage 4 is advanced care. Proceeding from stage 1 to other stages may happen immediately or over many years. Stage 1: Identification and documentation of tobacco use is part of each patient's medical history and included into oral examination with no extra compensation. Stage 2: Brief intervention consists of a motivational interview and providing information about existing support. This stage should be coded/reimbursed as a short preventive intervention similar to other advice for oral care. Stage 3: Intermediate care consists of a motivational interview, assessment of tobacco dependency, informing about possible support and pharmacotherapy, if appropriate. This stage should be coded as preventive intervention similar to an oral hygiene instruction. Stage 4: Advanced care. Treatment codes should be created for advanced interventions by oral health professionals with adequate qualification. Interventions should follow established guidelines and use the most cost-effective approaches.

Continuing education of tobacco use cessation (TUC) for dentists and dental hygienists

Tobacco use prevention (TUC) guidelines are mostly designed for undergraduate education. Most practising dental professionals have not been trained in TUC and so current and future guidelines need to be adapted for continuing education. It is important to motivate dental professionals to be involved in TUC. 'The 3 Ts' is one suggested method of stimulating this motivation. Two levels of TUC are recommended, and both brief advice and enhanced interventions can be incorporated into routine practice. It is recommended that TUC continuing education on these interventions should be provided by a team of dental and trans- disciplinary experts. The maintenance of TUC involvement can be divided in individual and collective strategies. The international dental professional organisations can provide important 'benchmarks' for minimum clinical standards and for the involvement of both national dental organisations and individual dental health professionals in TUC continuing education.

Periodontal disease in a group of Swedish adult snuff and cigarette users

The aim of this study was to compare the prevalence of periodontal disease in different groups of tobacco users. Participants (n = 1674) were selected from an initial random sample of residents in the Stockholm region. Socio-demographic characteristics and life-time history of tobacco use were registered in a self-completed questionnaire, followed by a clinical examination. Cumulative life-time tobacco use was analyzed in pack-years and can-years as the exposure of interest. Among participants, 50.8% were females and 49.2% were males. Life-time tobacco use was categorized into four mutually exclusive categories. Approximately, two-thirds of snuff users had combined snuff use with cigarette smoking during their life. Tobacco users had a higher prevalence of periodontal disease compared to never users. Exclusive smokers and mixed users presented the less favorable situation. Unhealthy periodontal conditions increased with increasing exposure to smoking, most evidently at the level of 15 or more pack-years. There was a significant positive association between current or former smoking and periodontal disease (OR = 2.7, CI = 1.7-4.3 and OR = 2.0, CI = 1.2-3.3, respectively) even after adjustment for plaque level. An indication of association was also apparent with former snuff use. Plaque was independently associated with periodontal disease, with a dose gradient. Smoking is associated with periodontal disease independently of plaque. Combining cigarette smoking and snuff use during life does not convey a decreased probability of being diagnosed with periodontal disease compared to smoking exclusively.

Cigarette smoking, snuff use and alcohol drinking: coexisting risk behaviours for oral health in young males

OBJECTIVES

The use of oral moist snuff (snus) is widespread among Swedish men, but little is known about the use in adolescents. The aim of this study was to describe patterns of snuff dipping, smoking and alcohol drinking in a sample (n = 6287) of 9th grade male students participating in a census survey in the Stockholm region.

RESULTS

About 20% of the sample reported use of snus, and more than two-thirds of snus users were also cigarette smokers. Among current nonusers of tobacco (66% of the sample), 14% reported frequent binge drinking, in contrast to 49% among current exclusive cigarette smokers, 60% among exclusive snus users and 69% among users of both cigarettes and snus. The estimated mean annual consumption of alcohol was 5-10 times higher among tobacco users than among nonusers, with users of snus consuming more alcohol than smokers. Compared to non- or minimal drinkers, heavy alcohol drinkers had a disproportionately higher risk to report snus use, after adjustment for smoking behaviour (OR = 16.7, 95% CI 12.9-21.7). When the analysis was restricted to users of only one type of tobacco, heavy drinkers were twice as likely to report snus, rather than cigarette, use.

CONCLUSIONS

Both tobacco use and alcohol drinking have been independently associated with a variety of pathological oral conditions in adults. These behaviours coexist in early adolescence. Their effect on oral health need to be investigated in prospective studies and should be of concern to the dental professionals.

Granulocyte elastase, matrix metalloproteinase-8 and prostaglandin E2 in gingival crevicular fluid in matched clinical sites in smokers and non-smokers with persistent periodontitis

BACKGROUND/AIMS

Smokers with persistent periodontitis may have granulocytes with impaired function. This study aimed to determine the levels of granulocyte elastase, matrix metalloproteinase-8 (MMP-8) and prostaglandin E2 (PGE2) in gingival crevicular fluid (GCF) in smokers and non-smokers with persistent periodontitis.

METHODS

We analyzed GCF from 70 matched sites in 29 periodontitis and 6 gingivitis sites in 34 subjects, 17 smokers, and 17 non-smokers. We also analyzed separately GCF from 28 of these subjects, 14 smokers and 14 non-smokers in 14 matched periodontitis sites. The following measurements were made: elastase complexed to alpha1-antitrypsin (EA-alpha1AT) and MMP-8 with ELISA, functional elastase with a chromogenic substrate, and PGE2 with radioimmunoassay (125I RIA). The significance of the findings was determined with Mann-Whitney test.

RESULTS

In the 29 matched periodontitis sites, smokers had significantly more functional elastase (p<0.005) and more EA-alpha1AT (p<0.05) than non-smokers. In the 14 matched periodontitis sites in 14 smokers and 14 non-smokers, the former had significantly more functional elastase than the latter (p<0.001). A significant correlation was found between EA-alpha1AT and MMP-8 in smokers (p<0.05) and non-smokers (p<0.001) and a positive correlation between levels of functional elastase and MMP-8 in non-smokers (r2=0.98; p<0.001).

CONCLUSIONS

Granulocyte function seems to be impaired in smokers with persistent periodontitis. The cells react to the bacterial challenge by releasing serine proteases, which reflect the degradation of connective tissue. The risk of progression of the disease is therefore higher in smokers with persistent periodontitis than in non-smokers.

Between harm and dangers. Oral snuff use, cigarette smoking and problem behaviours in a survey of Swedish male adolescents

BACKGROUND

The prevalence of smokeless tobacco use (moist snuff) in Sweden is among the highest world-wide, and snuff is gaining popularity as a less harmful alternative to cigarettes.

METHODS

Patterns of current tobacco use and indicators of behavioural problems were analysed in a sample of 6287 boys participating in a census survey among 9th graders in Stockholm County, Sweden.

RESULTS

Among participants reporting current use of oral snuff (OS) the majority (71%) also smoked cigarettes. The prevalence of daily smoking was significantly higher in this group than among exclusive smokers. Conditionally on smoking behaviour, the likelihood of being a current user of OS was several times higher among boys who had ever been drunk (adjusted odds ratio = 9.64, 95% confidence interval: 7.32-12.94) or experimented with illicit drugs (adjusted odds ratio = 2.39, 95% confidence interval: 1.99-2.87), compared with those who did not. OS use was also significantly associated to other problem behaviours such as drinking and driving, unsafe sex, and school truancy. The same pattern of associations was present when the analyses were restricted to tobacco users.

CONCLUSIONS

Smokeless tobacco use in adolescence does not substitute cigarette smoking and can be an indicator of a drug- and risk-seeking lifestyle. The availability of smokeless tobacco might thus increase the potential for nicotine addiction in some vulnerable subgroups of young males.