eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa
Smokeless Tobacco Lesions: Treatment & Medication
Updated: Nov 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
To reduce the risk of progression to oral cancer, smokeless tobacco use should be minimized, with cessation encouraged. The National Cancer Institute recommends that clinicians use the "4 A 's," as follows:
- Ask about tobacco use
- Advise patients to quit smoking
- Assist patients in quitting
- Arrange follow-up
Both the nicotine patch (in variable doses) and bupropion are helpful in treating nicotine dependence, with an additive effect when used in combination. Other medications useful in treating nicotine dependence include nicotine nasal spray inhalers; nicotine gum; and nontobacco snuff products containing mint, clover, alfalfa, and flavorings.
In 2000, Horn and colleagues14 reported that West Virginian athletes were particularly vulnerable to smokeless tobacco use. The study concluded that both middle and high school coaches were willing to help athletes quit and should act as smokeless tobacco intervention agents.
The National Spit Tobacco Education Program (NSTEP)15 is a national organization committed to minimizing the risk of oral cancers associated with smokeless tobacco through education. This organization does not advocate smokeless tobacco use as a healthier alternative to cigarette smoking. NSTEP targets education to the general public and specifically to baseball players and their families, in whom the use of smokeless tobacco is extremely high. In fact, NSTEP is supported and endorsed by both Major League Baseball and Little League Baseball.
Surgical Care
Biopsy should be performed on lesions of erythroplasia that are suggestive of cancer based on their appearance or location in the oral cavity or those that have failed to resolve within 2-3 weeks. Premalignant lesions and CIS may be permanently cured after excision or biopsy. Primary and invasive SCCs are treated with varying combinations of surgery and/or radiation.
Once a diagnosis of oral cancer is established, the therapeutic approach is multidisciplinary.
Consultations
Treatment for oral cancer may involve consultation with the following:
Diet
A poor diet has been related to the development of oral cancer, but the substances in healthy foods responsible for this difference remain unclear.
Medication
Both the nicotine patch (in variable doses) and bupropion are helpful in treating nicotine dependence, with an additive effect when used in combination. Other medications useful in treating nicotine dependence include nicotine nasal spray inhalers; nicotine gum; nicotine lozenges; and nontobacco snuff products containing mint, clover, alfalfa, and flavorings. In addition, varenicline was approved by the US Food and Drug Administration in 2006 to help cigarette smokers quit. It also may help users of smokeless tobacco quit by decreasing their withdrawal symptoms.
A case published in the Journal of the American Medical Association was the first to document the efficacy of bupropion for the treatment of smokeless tobacco addiction.16 A 31-year-old man, with a history of a 1 can/d use of smokeless tobacco for 11 years, had previously attempted to quit using nicotine patches and abrupt cessation. He underwent a 4-week course in behavior modification including coping strategies and maintenance skills and set a quit date. Bupropion (150 mg bid) was started 1 week prior to group therapy and was continued for 10 weeks total. After 1 week, his cravings were reduced, and at 5 weeks, he was tobacco free. The patient remained tobacco free at 8 months.
The following Medscape CME courses may be of interest:
- Varenicline May Be Better Than Transdermal Nicotine Replacement to Quit Smoking
- "Cut Down to Quit" -- New Designation for Nicotine Replacement Therapy: A Best Evidence Review
Smoking deterrents
These agents are used to aid in smoking cessation, while the patient participates in a behavioral modification program under medical supervision.
Nicotine transdermal system (Nicotrol)
Works best when used in conjunction with a support program, such as counseling, group therapy, or behavioral therapy.
Adult
1 transdermal patch of 15 mg/d for 6 wk, then 1 transdermal patch of 10 mg/d for 2 wk, followed by 1 transdermal patch of 5 mg/d for 2 wk
Pediatric
Not established
May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke or use snuff, chewing tobacco, or other nicotine products (may increase toxicity of nicotine)
Documented hypersensitivity; use in nonsmokers, children, pregnancy, life-threatening arrhythmias, or severe or worsening angina pectoris
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction; may cause skin irritation
Nicotine polacrilex nasal spray (Nicotrol NS)
Intranasal nicotine may closely approximate the time course of plasma nicotine levels observed after cigarette smoking.
Adult
1-2 sprays/h; each spray contains 0.5 mg of nicotine; not to exceed more than 10 sprays/h (5 mg)
Pediatric
Not established
May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke or use snuff, chewing tobacco, or other nicotine products (may increase toxicity of nicotine)
Documented hypersensitivity; use in nonsmokers, children, pregnancy, life-threatening arrhythmias, or severe or worsening angina pectoris
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction
Nicotine transdermal system 21-mg patch (NicoDerm CQ, Habitrol)
Works best when used in conjunction with a support program, such as counseling, group therapy, or behavioral therapy.
Adult
One 21-mg patch qd for 6 wk, then one 14-mg patch qd for 2 wk, followed by one 7-mg patch qd for 2 wk
Pediatric
Not established
May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke or use snuff, chewing tobacco, or other nicotine products (may increase toxicity of nicotine)
Documented hypersensitivity; use in nonsmokers, children, pregnancy, life-threatening arrhythmias, or severe or worsening angina pectoris
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction; may cause skin irritation
Nicotine polacrilex (Nicorette)
The nicotine is absorbed through the oral mucosa. Quickly absorbed and closely approximates time-course of plasma nicotine levels after cigarette smoking.
Adult
1 piece of gum (2 mg) per hour prn to abstain from smoking; not to exceed 30 mg/d
Pediatric
Not established
May decrease diuretic effects of furosemide and decrease cardiac output; may decrease absorption of glutethimide; may increase circulating cortisol and catecholamines; do not use if patient continues to smoke or use snuff, chewing tobacco, or other nicotine products (may increase toxicity of nicotine)
Documented hypersensitivity; use in nonsmokers, children, pregnancy, life-threatening arrhythmias, or severe or worsening angina pectoris
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in peptic ulcer, coronary artery disease, angina, hypertension, peripheral arterial disease, diabetes, severe renal dysfunction, and hepatic dysfunction
Bupropion (Zyban, Wellbutrin)
Used in conjunction with a support group and/or behavioral counseling. Inhibits neuronal dopamine reuptake. Also a weak blocker of serotonin and norepinephrine reuptake.
Adult
150-mg tab PO qd for 3 d, then increase to 150 mg bid for 7-12 wk, with at least 8 h between each dose
Pediatric
Not established
Carbamazepine, cimetidine, phenytoin, and phenobarbital may decrease effects; toxicity increases with concurrent administration of levodopa and MAOIs
Documented hypersensitivity; seizure disorder; anorexia nervosa; concurrent use with MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or hepatic insufficiency; doses >450 mg/d significantly decrease seizure threshold
Varenicline (Chantix)
Partial agonist selective for alpha4, beta2 nicotinic acetylcholine receptors. Action is thought to result from activity at a nicotinic receptor subtype, where its binding produces agonist activity while simultaneously preventing nicotine binding. Agonistic activity is significantly lower than nicotine. Also elicits moderate affinity for 5-HT3 receptors. Maximum plasma concentrations occur within 3-4 h after oral administration. Following regular dosing, steady state reached within 4 d.
Adult
Initiate 1 wk before date chosen to stop smoking
Days 1-3: 0.5 mg PO qd pc
Days 4-7: 0.5 mg PO bid pc
Day 8 to end of treatment: 1 mg PO bid pc
Continue treatment for 12 wk; if successfully stopped smoking at end of 12 wk, an additional 12-wk course is recommended; take pc with full glass of water
Severe renal impairment (ie, CrCl <30 mL/min): Not to exceed 0.5 mg PO bid
End-stage renal disease with hemodialysis: Not to exceed 0.5 mg PO qd
Pediatric
<18 years: Not established
Data limited; coadministration with nicotine replacement therapy may increase incidence of nausea, headache, vomiting, dizziness, and dyspepsia compared with nicotine replacement therapy alone
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include nausea, headache, vomiting, flatulence, insomnia, abnormal dreams, and dysgeusia; decrease dose with severe renal impairment (ie, CrCl <30 mL/min) or end-stage renal disease undergoing hemodialysis
Serious neuropsychiatric symptoms have been reported during postmarketing surveillance and may include changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide; these adverse events have been exhibited in patients without preexisting psychiatric illness, and patients with preexisting psychiatric illness have reported worsening symptoms during varenicline treatment; for more information, see the FDA MedWatch Safety Information
More on Smokeless Tobacco Lesions |
| Overview: Smokeless Tobacco Lesions |
| Differential Diagnoses & Workup: Smokeless Tobacco Lesions |
 Treatment & Medication: Smokeless Tobacco Lesions |
| Follow-up: Smokeless Tobacco Lesions |
| Multimedia: Smokeless Tobacco Lesions |
| References |
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References
[Best Evidence] Luo J, Ye W, Zendehdel K, Adami J, Adami HO, Boffetta P, et al. Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. Jun 16 2007;369(9578):2015-20. [Medline].
Hassan MM, Abbruzzese JL, Bondy ML, Wolff RA, Vauthey JN, Pisters PW, et al. Passive smoking and the use of noncigarette tobacco products in association with risk for pancreatic cancer: a case-control study. Cancer. Jun 15 2007;109(12):2547-56. [Medline].
Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. May 10 2005;114(6):992-5. [Medline].
Alguacil J, Silverman DT. Smokeless and other noncigarette tobacco use and pancreatic cancer: a case-control study based on direct interviews. Cancer Epidemiol Biomarkers Prev. Jan 2004;13(1):55-8. [Medline].
Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. State-specific prevalence among adults of current cigarette smoking and smokeless tobacco use and per capita tax-paid sales of cigarettes--United States, 1997. JAMA. Jan 6 1999;281(1):29-30. [Medline].
Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Dent Assoc. Sep 2004;135(9):1279-86. [Medline].
Ahmed HG, Mahgoob RM. Impact of Toombak dipping in the etiology of oral cancer: gender-exclusive hazard in the Sudan. J Cancer Res Ther. Apr-Jun 2007;3(2):127-30. [Medline].
Scheifele C, Nassar A, Reichart PA. Prevalence of oral cancer and potentially malignant lesions among shammah users in Yemen. Oral Oncol. Jan 2007;43(1):42-50. [Medline].
Martin GC, Brown JP, Eifler CW, Houston GD. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. Jul 1999;130(7):945-54. [Medline].
Tilashalski K, Rodu B, Mayfield C. Assessing the nicotine content of smokeless tobacco products. J Am Dent Assoc. May 1994;125(5):590-2, 594. [Medline].
Yildiz D, Liu YS, Ercal N, Armstrong DW. Comparison of pure nicotine- and smokeless tobacco extract-induced toxicities and oxidative stress. Arch Environ Contam Toxicol. Nov 1999;37(4):434-9. [Medline].
Wray A, McGuirt WF. Smokeless tobacco usage associated with oral carcinoma. Incidence, treatment, outcome. Arch Otolaryngol Head Neck Surg. Sep 1993;119(9):929-33. [Medline].
Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health. Mar 1994;84(3):399-404. [Medline].
Horn KA, Maniar SD, Dino GA, Gao X, Meckstroth RL. Coaches' attitudes toward smokeless tobacco and intentions to intervene with athletes. J Sch Health. Mar 2000;70(3):89-94. [Medline].
National Spit Tabacco Education Program. Available at http://www.nstep.org. Accessed June 20, 2002.
Berigan TR, Deagle EA 3rd. Treatment of smokeless tobacco addiction with bupropion and behavior modification. JAMA. Jan 20 1999;281(3):233. [Medline].
Ayo-Yusuf OA, Swart TJ, Ayo-Yusuf IJ. Prevalence and pattern of snuff dipping in a rural South African population. SADJ. Nov 2000;55(11):610-4. [Medline].
Connolly GN, Winn DM, Hecht SS, Henningfield JE, Walker B Jr, Hoffmann D. The reemergence of smokeless tobacco. N Engl J Med. Apr 17 1986;314(16):1020-7. [Medline].
Framer ER, Hood AF. Pathology of the Skin. Norwalk, Conn: Appleton & Lange; 1990:918-23.
Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA Cancer J Clin. Jan-Feb 2001;51(1):15-36. [Medline].
Hong WK, Lippman SM, Itri LM, Karp DD, Lee JS, Byers RM, et al. Prevention of second primary tumors with isotretinoin in squamous-cell carcinoma of the head and neck. N Engl J Med. Sep 20 1990;323(12):795-801. [Medline].
Katz SI, Wolff K. Fitzpatrick's Dermatology in General Medicine. 5th ed. New York, NY: McGraw-Hill; 1998:1309-14.
Mitchell BE, Sobel HL, Alexander MH. The adverse health effects of tobacco and tobacco-related products. Prim Care. Sep 1999;26(3):463-98. [Medline].
National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Program. 2001. National Cancer Institute. Available at http://seer.cancer.gov. Accessed June 20, 2002.
Smith SS, Fiore MC. The epidemiology of tobacco use, dependence, and cessation in the United States. Prim Care. Sep 1999;26(3):433-61. [Medline].
Taybos G. Oral changes associated with tobacco use. Am J Med Sci. Oct 2003;326(4):179-82. [Medline].
Tilashalski K, Rodu B, Cole P. A pilot study of smokeless tobacco in smoking cessation. Am J Med. May 1998;104(5):456-8. [Medline].
Wallner PE, Hanks GE, Kramer S, McLean CJ. Patterns of Care Study. Analysis of outcome survey data-anterior two-thirds of tongue and floor of mouth. Am J Clin Oncol. Feb 1986;9(1):50-7. [Medline].
Walsh PM, Epstein JB. The oral effects of smokeless tobacco. J Can Dent Assoc. Jan 2000;66(1):22-5. [Medline].
Further Reading
Keywords
oral lesions, premalignant leukoplakia, leukoplakia, speckled leukoplakia, carcinoma in situ, CIS, squamous cell carcinoma, SCC, oral cancer, buccal mucosal cancer, erythroplasia, erythroplakia, tobacco-associated keratosis, verrucous carcinoma, snuff dipper's cancer
