[Adverse effects of Swedish smokeless tobacco "snus"]. / Nuuskan terveyshaitat.

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.

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.