Smokeless tobacco cessation

Mechanisms of Cancer Induction by Tobacco-Specific NNK and NNN

Tobacco use is a major public health problem worldwide. Tobacco-related cancers cause millions of deaths annually. Although several tobacco agents play a role in the development of tumors, the potent effects of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN) are unique. Metabolically activated NNK and NNN induce deleterious mutations in oncogenes and tumor suppression genes by forming DNA adducts, which could be considered as tumor initiation. Meanwhile, the binding of NNK and NNN to the nicotinic acetylcholine receptor promotes tumor growth by enhancing and deregulating cell proliferation, survival, migration, and invasion, thereby creating a microenvironment for tumor growth. These two unique aspects of NNK and NNN synergistically induce cancers in tobacco-exposed individuals. This review will discuss various types of tobacco products and tobacco-related cancers, as well as the molecular mechanisms by which nitrosamines, such as NNK and NNN, induce cancer.

A cessation program for snuff-dippers with long-term, extensive exposure to Swedish moist snuff: A 1-year follow-up study

OBJECTIVE

Smokeless tobacco (Swedish moist 'snus') users are often strongly addicted to nicotine. Compared to the large number of smoking-cessation studies, there have been few evaluated clinical cessation programs in conjunction with nicotine replacement therapy (NRT). The aim of this study was to evaluate a cessation program for snus users with a weekly use of >2 cans/week for >10 years.

MATERIAL AND METHODS

A prospective, open, non-randomized intervention trial was undertaken including baseline oral examination and soft tissue biopsy, minor physical examination, brief cessation advice, NRT recommendations and five prospective follow-up visits within 12 months. Individual cessation counseling was given, together with oral examination in the dental office. Fifty snus users with a minimum consumption of 100 g/week who were actively seeking cessation treatment were recruited through advertising. Self-reported abstaining, including random-sample biochemical verification, and NRT use were evaluated at 6 weeks and 3, 6 and 12 months.

RESULTS

At the 3-, 6- and 12-month visits, 58%, 46% and 30% of subjects, respectively were tobacco-abstinent. All nicotine abstinence was randomly controlled during the study except at 12 months, where all subjects claiming abstinence were confirmed biochemically and clinically.

CONCLUSION

Smokeless tobacco cessation achieved together with suitable NRT seems a promising way to improve a persistent tobacco-free condition.

A eficácia das intervenções farmacológicas e psicossociais para o tratamento do tabagismo: revisão da literatura

A cessação do tabagismo traz benefícios à saúde, pois indivíduos que param de fumar evitam a maioria das doenças associadas ao tabaco. Objetiva-se revisar as características fundamentais e eficácia das intervenções farmacológicas e psicossociais para o tratamento dos tabagistas, apresentando dados de revisões tipo meta-análises e de ensaios clínico randomizados. Intervenções farmacológicas como a terapia de reposição de nicotina e a bupropiona e intervenções psicossociais como a terapia cognitivo-comportamental e a intervenção motivacional face a face e por telefone demonstram eficácia. A farmacoterapia aumenta a chance de abstinência em 2 vezes e as intervenções psicossociais face a face ou por telefone em 1,5 a 2,5 vezes em relação a tabagistas recebendo intervenções controles. Estes dados fornecem subsídios para profissionais de saúde decidirem qual o melhor tratamento para o tabagista, informando as intervenções disponíveis, sua eficácia e o benefício de sua utilização.

Smokeless tobacco brand switching: a means to reduce toxicant exposure?

The purpose of this study was to examine the effects of smokeless tobacco (ST) brand switching on biomarkers of ST exposure and on ST use. Subjects seeking treatment to reduce their use were randomized to ST brand switching with controlled ST topography, brand switching with ad libitum ST use, or a waitlist control with subsequent randomization to one of these two conditions. The waitlist control group was included to assess whether changes were a consequence of time effect. During the intervention, Copenhagen or Kodiak ST users were asked to switch to products that were sequentially lower in nicotine content: Skoal Long Cut Straight or Wintergreen for 4 weeks and then Skoal Bandits for the subsequent 4 weeks. Measures were obtained during the course of treatment and at 12-week follow-up. Significant reductions in total urinary cotinine and 4-(methylnitrosamino)-L-(3-pyridyl)-L-butanol (NNAL) plus its glucuronides (total NNAL) were observed with no significant differences between the controlled topography and ad libitum conditions. Significant reductions were also observed in the amount and duration of dips with a significant intervention effect for durational measures. At 12 weeks, the 7-day biochemically-verified tobacco abstinent rate was 26% in the ad libitum group. ST brand switching may be a feasible alternative intervention for ST users interested in quitting but unwilling to stop ST use completely.

The epidemiology of tobacco use and dependence

Tobacco use continues to be a public health issue of great importance. Acute and critical care nurses in particular have a unique opportunity to become a cornerstone for the nation's tobacco control efforts through integration of prevention and cessation interventions as part of patient care. This article provides readers with a working knowledge of tobacco use and dependence as background reading for the subsequent articles presented in this special issue addressing tobacco cessation in acute and critical care settings.

What have we learned from 20 years of research on smokeless tobacco cessation?

Although smoking cessation continues to get most of the attention from both researchers and practitioners, treatment for smokeless tobacco (SLT) dependence gets little consideration. The reasons are varied, but essentially smoking is more prevalent, has greater public health implications, and has been the subject of clean air laws and environmental issues that have focused the attention on a burned tobacco, thereby leaving SLT with scant public health attention. This is unfortunate, because the sales of SLT products, especially moist snuff, have increased consistently over the past decade; regular use of these products can result in oral cancer, other negative effects on oral health, and nicotine dependence or addiction. This article will review some unique issues of SLT use that affect cessation and the empirical research on interventions.

Consenso sobre o tratamento da dependência de nicotina

Têm sido atribuídas à dependência de nicotina 20% das mortes nos EUA. Estudos têm mostrado que 30% a 50% das pessoas que começam a fumar escalam para um uso problemático. Nos últimos 20 anos, a educação e a persuasão não foram suficientes para promover uma mudança política, cultural e social relacionada ao comportamento de fumar. As intervenções para interromper o uso de tabaco ainda não estão integradas às rotinas dos serviços de saúde no mundo. A falta de estratégias de integração, de tempo disponível para acoplar ações assistenciais mais específicas e mesmo a percepção dos profissionais de saúde de que os tratamentos para a dependência de nicotina são pouco efetivos são algumas das barreiras apontadas. Assim, elaborar um consenso sobre a dependência de nicotina teve como objetivos: • levantar dados epidemiológicos relevantes relacionados ao uso do tabaco no mundo e no Brasil; • revisar as ações gerais e centrais da nicotina; • elaborar um protocolo de triagem mínimo para serviços de atenção primária à saúde; • recomendar diretrizes básicas de avaliação, diagnóstico e tratamento para todos os níveis de atenção à saúde em relação à dependência de nicotina; • fornecer sugestões para a abordagem de grupos especiais de pacientes: adolescentes, gestantes, idosos, pacientes em regime de internação, obesos e pacientes com comorbidades psiquiátricas, cardiovasculares e respiratórias.