Learning objectives - the Conference Exchange...Basic Principles of MI Integration Principles Goals Express Empathy Build Rapport Develop Discrepancy Elicit Pros and Cons Roll with

Slide 1

Precancerous Oral Conditions in Nevada Adolescents Associated with Tobacco and Marijuana Use

Drs. Marcia Ditmyer*£, Christina Demopoulos£, Connie Mobley£

*Academy for Academic Leadership

£University of Nevada, Las Vegas, School of Dental Medicine

Abstract ID: 306576

November 19, 2014

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Slide 2

All speakers agree that neither they nor members of their immediate family have any financial

relationships with commercial entities that may be relevant to their presentation.

Disclosure Statement

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Slide 3

Learning objectives

1. Describe the history of the Nevada Clean Indoor Air Act and its effect on precancerous oral conditions in Nevada youth.

2. Compare differences and linear associations between oral lesions/enlarged lymph nodes in reported users and non-users of cigarettes/marijuana.

3. Compare oral differences and linear associations between oral lesions/enlarged lymph nodes in reported subjects exposed to environmental tobacco smoke (ETS).

4. Discuss potential interventions to change the environment regarding adolescent cigarette and marijuana use.

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Slide 4

Nevada Clean Indoor Air Act

• Nevadans voted on November 7, 2006 to enact the Nevada Clean Indoor Air Act (Question 5) in order to protect themselves and their families from the dangers of ETS.

• Question 5 received over 54 percent of the vote and became law on December 8, 2006.

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Slide 5


• Public/private school buildings and on

public/private school grounds

• Child care facilities with >five children

• All areas of grocery stores, convenience

stores, and drug stores

• All indoor areas within restaurants,

including those in casinos

• Bars, taverns and saloons that serve

food

• Shopping malls and retail stores.

• Video arcades

• Movie theaters

• Government buildings and public places

Smoking tobacco in any form is now prohibited in places like:

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Slide 6


• During the 2011 legislative session lawmakers passed Assembly Bill 571 which made changes to the voter-approved act.

• Based on these revisions to the statute, stand-alone bars, taverns and saloons in which patrons under 21 years of age are prohibited from entering, may allow smoking.

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Slide 7 Tobacco Use

• Tobacco is the leading cause of preventable death worldwide (>5 million per year)

• More than $289 billion a year, including at least $133 billion in direct medical care for adults and more than $156 billion in lost productivity

• In 2012, 18.1% of all adults (42.1 million people): 20.1% of males, 14.5% of females smoked cigarettes

• Tobacco use predicted to kill more than 8 million people worldwide by 2030 and 1 billion by the end of the century.

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Slide 8 Lifetime Prevalence of Marijuana Use

• Marijuana use has been linked to adverse health conditions and greater concentrations of carcinogens than tobacco.

Group 2009 2012

8th graders 15.7% 16.4%

10th graders 32.3% 34.5%

12th graders 42.0% 45.5%

College students* 47.5% 46.6%

Young adults (19-28)* 56.0% 56.3%

*Numbers may overlap in results.

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Slide 9 Purpose of Study

To determine significant associations between tobacco/marijuana use and precancerous oral conditions (oral lesions and enlarged lymph nodes) in Nevada adolescents.

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Slide 10 Background

• Ongoing statewide school-based dental health screening initiative (2002 to 2010) known as Crackdown on Cancer

• Public and private middle and high-schools invited to participate.

• Funded by Master Settlement Agreement allocated to the Trust Fund for Public Health and the Fund for a Healthy Nevada.

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Slide 11

Methods

• 31,306 screenings of adolescents between 13-19 from 2006/2010 (The year the Nevada Clean Air Act went into Law)

Year 1 Year 2 Year 3 Year 4

Year and Total

N-value

2006–2007

N = 7,290

2007–2008

N = 7,378

2008–2009

N = 7,064

2009–2010

N = 7,163

n (%) n (%) n (%) n (%)

Total Identified 288 (0.04) 632 (0.09) 365 (0.05) 428 (0.06)

Note: N=1713, with 71 overlapping cases; 826 with oral lesions and 887 with

enlarged lymph nodes.

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Slide 12

Methods

• Examinations conducted by licensed/calibrated dentists, hygienists, and dental hygiene students.

• UNLV IRB approved this initiative to assure participant confidentiality and protection.

• Precancerous lesions were defined as any oral lesion and any enlarged lymph nodes not related to known disease.

• Tobacco use and ETS were self-reported.

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Slide 13

Methods

•Descriptive (frequency/percentage).

•Percent Change (PC) – when comparing an old value and a new value. Used to see changes from year-to-year.

•Percent Mean Difference (PMD) used to assess differences in percentages within each year on various demographic variables.

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Slide 14

RESULTS

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Slide 15 Tobacco and Marijuana Use 2006-2010, By Type


Year and Total

N-value

2006–2007

N = 7,290

2007–2008

N = 7,378

2008–2009

N = 7,064

2009–2010

N = 7,163

n (%) n (%) n (%) n (%)

Total Identified 288 (0.04)* 632 (0.09)* 365 (0.05)* 428 (0.06)*

No Tobacco 25 (08.8)** 39 (06.1)** 74 (20.3)** 109 (25.5)**

Tobacco£ 133 (46.1)** 139 (21.9)** 147 (40.3)** 173 (40.4)**

Marijuana 130 (45.1)** 454 (71.8)** 144 (39.4)** 146 (34.1)**

*Percentage of total screened; **Percentage of those identified with

lesions/enlarged lymph nodes; £Tobacco includes cigarettes, cigars, and chew.

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Slide 16 Tobacco and Marijuana Use 2006-2010, By Type

2539

74

109133 139 147

173

130

454

144 146

0

50

100

150

200

250

300

350

400

450

500


No Tobacco Tobacco£ Marijuana

Significant linear correlation

(p=0.01) between tobacco

use and oral lesions or

enlarged lymph nodes across

the years, with exception in

year 2.

Significant differences in

year 2 between tobacco use

and identified lesions and

lymph nodes (p=0.04)

£ Includes Cigarettes, Chew, and Cigars; Controlled for gender and ETS

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Slide 17 Differences between Males and Females, 2006 - 2010


Year and Total

N-value

2006–2007

N = 7,290

2007–2008

N = 7,378

2008–2009

N = 7,064

2009–2010

N = 7,163

n (%) n (%) n (%) n (%)


Males 174 (60.4)** 364 (57.6)** 234 (64.1)** 281 (65.6)**

Females** 114 (39.5)** 265 (41.9)** 131 (35.9)** 145 (33.9)**

*Percentage computed out of the total screened; **Percentage computed from those

identified with lesions/enlarged lymph nodes

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Slide 18 Differences between Males and Females, 2006 - 2010

174

364

234

281

114

265

131145

0

50

100

150

200

250

300

350

400


Males Females**

Significant linear correlation

between males/females and

oral lesions or enlarged

lymph nodes (p=0.005).


years 2 (p=0.001) and 4 (p=-

.01) between males and

females and identified

lesions and lymph nodes.

Controlled for ETS

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Slide 19

ETS Exposure, 2006 - 2010Year 1 Year 2 Year 3 Year 4

Year and Total

N-value

2006–2007

N = 7,290

2007–2008

N = 7,378

2008–2009

N = 7,064

2009–2010

N = 7,163

n (%) n (%) n (%) n (%)


Exposed 179 (62.2)** 603 (95.4)** 192 (52.6)** 234 (54.7)**

Not Exposed 109 (37.8)** 29 (0.05)** 173(47.4)** 194 (45.3)**

*Percentage of total screened; **Percentage of those identified with

lesions/enlarged lymph nodes; SHS exposure was self-reported

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Slide 20 ETS Exposure, 2006-2010

0

100

200

300

400

500

600

700


Exposed Not Exposed

No significant correlations

between ETS and oral lesions

or enlarged lymph nodes.


year 2 between those who

were exposed and those not

exposed to ETS and

identified lesions and lymph

nodes.

Controlled for differences between males and females

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Slide 21

DISCUSSION AND RECOMMENDATIONS

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Slide 22

Discussion

• Approximately 42,440 Americans will be diagnosed with oral or

pharyngeal cancer this year.

• Cause over 8,390 deaths, killing roughly 1 person per hour, 24

hours per day.

• Each year in the United States, more than 21,000 men and 9,000

women are diagnosed with oral cancer. Most are over 60 years

old.

• Because of the HPV Virus, it is becoming more prevalent in

adolescence. Depending on the source – it has or will surpass

tobacco as a risk factor.

Source: National Cancer Institute and CDC, 2014

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Slide 23 Questions to Ask Patients Regarding Tobacco and Marijuana Use

1. Do you use any form of tobacco or marijuana?

2. How much do you use?

a) Tobacco (Number of cigarettes in a day/week)

b) Marijuana (Number of joints in a day/week)

3. How long after you wake up do you have to use tobacco and/or marijuana?

4. Have you ever quit?

a) If so, how long (<30 days, >30 days); what did you do to help you quit?

5. Are you interested in quitting?

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Slide 24 Patient-Centered Counseling ModelStrategies for Behavior Change

1. Motivational Interviewing

2. Stages of Change

3. Payoff Matrix

4. ICR Readiness Ruler

5. 5A’s Model

6. Value Cards

7. Reflective Listening

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Slide 25 Basic Principles of MI Integration

Principles Goals

Express Empathy Build Rapport

Develop Discrepancy Elicit Pros and Cons

Roll with Resistance Respect Patient Autonomy

Support Self-Efficacy Communicate that the patient is

capable of change

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Slide 26 ACTION STEPS

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Slide 27 PAYOFF MATRIX (Example)

Behavior

(Drinking Alcohol)

Alternate Behavior

(Quit Drinking Alcohol)

Pros

Advantages

Helps me relax

Enjoy drinking with friends

Eases boredom and reduces

depression

Feel better physically

Have more $

Less conflict with family, work,

some friends

Cons

Disadvantages

Hard on my health, including

oral health

Spending too much $

Might lose my job

Teeth will look bad and cause

me to be uncomfortable

I’d miss getting that “buzz”

What to do about friends who

drink?

How to deal with stress of not

drinking?

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Slide 28 ICR Readiness Ruler (Example)

• How Important is it for you to change right now?

• How Confident are you that you could do it?

• How Ready are you to change right now?

1 2 3 4 5 6 7 8 9 10

Not at all

Important

Somewhat

Important

Extremely

Important

1 2 3 4 5 6 7 8 9 10

Not at all

Confident

Somewhat

Confident

Extremely

Confident

1 2 3 4 5 6 7 8 9 10

Not at all

Ready

Somewhat

Ready

Extremely

Ready

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Slide 29 5 A’s Model of Behavior Change

1A Assess – current behavior, importance of changing it, self efficacy,

stage of readiness, social support

2A Advise – clear, specific, and personalized behavior change, including

information about personal health harms/benefits.

3A Agree – collaboratively on the behavior to target (may be several),

next steps based on stage of readiness

4A Assist – self-help and/or counseling including goal setting and action

planning to develop skills, confidence, support to achieve goals

5A Arrange – follow-up (in person or by telephone) to discuss progress,

barriers, adjusting plan

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Slide 30

Discussion!

1. What do you think the impact on oral health might be with the legalization of marijuana?

2. How can healthcare providers better address the risk of non-traditional risk factors for oral cancer (i.e., Hookah, HPV, marijuana, e-cigarettes etc.) as they are growing trends in adolescents?

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Slide 31 References

• Axelsson, P., Paulander, J., Lindhe, J. (1998). Relationship between smoking and dental

status in 35, 50-, 65-, and 75-year-old individuals. Journal of Clinical Periodontology, 25,

297-305.

• Boulos, D. N. K., Loffredo, C. A., Setouhy, M. E., Abdel-Aziz, F., Israel, E., & Mohamed, M.

K. Nondaily, light daily, and moderate-to-heavy cigarette smokers in a rural area of Egypt:

A population-based survey. Nicotine & Tobacco Research, 11(2), 134-138. doi:

10.1093/ntr/ntp016

• Centers for Disease Control and Prevention [CDC]. (2002). Annual smoking-attributable

mortality, years of potential life lost, and economic costs—United States, 1995–1999.

Morbidity and Mortality Weekly Report, 51(14), 300–303. Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm

• Centers for Disease Control and Prevention [CDC]. (2008). Smoking-attributable mortality,

years of potential life lost, and productivity losses—United States, 2000–2004. Morbidity

and Mortality Weekly Report. 57(45), 1226–1228. Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm

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Slide 32

References

• Ditmyer, M. M., Mobley, C., Draper, Q., Demopoulos, C., & Smith, E.S. (2008).

Development of a theoretical screening tool to assess caries risk in Nevada youth. Journal

of Public Health Dentistry, 68(4), 201-208. doi: 10.1111/j.1752-7325.2007.00066.x

• Gilpin, E. A., White, M. M, Farkas, A. J., & Pierce, J. P. (1999). Home smoking restrictions:

Which smokers have them and how they are associated with smoking behavior. Nicotine

and Tobacco Research, 1(2):153-162. doi: 10.1080/14622299050011261

• Healthy People 2020. (2011). 2020 Topics and Objectives. Retrieved

fromhttp://healthypeople.gov/2020/topicsobjectives2020/default.aspx

• Johnston, L. D., O’Malley, P. M., Bachman, J.G., & Schulenberg, J.E. (2011). Monitoring

the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2010. Ann

Arbor: Institute for Social Research, The University of Michigan.

• National Institute on Drug Abuse [NIDA]. (2011). Info Facts: High School and Youth Trends.

• National Institutes of Health, US Department of Health and Human Services. Retrieved

from www.nida.nih.gov/infofacts/hsyouthtrends.html

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Slide 33

References• Johnston, L. D., O’Malley, P. M., Bachman, J.G., & Schulenberg, J.E. (2011). Monitoring the Future

National Results on Adolescent Drug Use: Overview of Key Findings, 2010. Ann Arbor: Institute for

Social Research, The University of Michigan.

• National Institute on Drug Abuse [NIDA]. (2011). Info Facts: High School and Youth Trends.

• National Institutes of Health, US Department of Health and Human Services. Retrieved from

www.nida.nih.gov/infofacts/hsyouthtrends.html

• Shenkin, J. D., Broffitt, B., Levy, S., Warren, J.J. (2004). The association between environmental

tobacco smoke and primary tooth caries. Journal of Public Health Dentistry, 64(3), 184-186.

• U.S. Department of Health and Human Services [USDHHS]. (2007). Trends in Oral Health Status:

United States, 1988-1944 and 1999 to 2004. Preliminary Report. Vital and Health Statistics,

11(248). DHHS Publication No. (PHS) 2007-1698, Hyattsville, MD.

• World Health Organization (WHO). (2011a). WHO Report on the global tobacco epidemic 2009,

Implementing Smoke-free environments: Executive Report. Retrieved from

http://whqlibdoc.who.int/hq/2009/WHO_NMH_TFI_09.1_eng.pdf

• World Health Organization (WHO). (2011b). Prevalence in tobacco use. Retrieved from

http://www.who.int/gho/tobacco/use/en/

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Slide 34

Questions ??

Acknowledgments

Source of Funding: Crackdown on Cancer Oral Health Surveillance Screening

Program receives funding through the Trust Fund for Public Health and The Fund

for Healthy Nevada, both beneficiaries of the Master Tobacco Settlement.

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Documents

Learning objectives - the Conference Exchange...Basic Principles of MI Integration Principles Goals Express Empathy Build Rapport Develop Discrepancy Elicit Pros and Cons Roll with