`If oral-health professionals would integrate short, consistent messages with their patients of all ages about the dangers of smokeless tobacco, there is no doubt in my mind that smokeless-tobacco-cessation rates among patients would increase dramatically.`
--Ken Manske, Director
The Tobacco Intervention Network, a not-for-profit organization established in 1989 and based in Gresham, Ore., has become a clearing house of information looking into the reasons people chew tobacco and how health professionals can become more comfortable at communicating with patients who chew or "dip" tobacco. Members of this free network get information, referrals to information resources, share anecdotal stories about different methodologies and gain skills in chewing-tobacco intervention. Their web site (www.quittobacco.com) has become a clearing house of publications, ideas, stories and a forum for health professionals interested in spit-tobacco cessation.
As a health-care marketing professional, I became interested in the tobacco issue as a recruiter for the National Institutes of Health`s nationwide lung health study. And, as a staff member at Oregon Health Sciences University in Portland, Ore., I had the opportunity to work with researchers on tobacco addiction and intervention. I became a senior research associate at the university`s public health department where I developed a seminar on the role of health advisors in smoking intervention and gave 200 presentations during the first year.
I learned that people in the medical profession are very interested and motivated to become involved with smokers. But, overall, dentists don`t share that same interest. Instead, they wanted to help when it came to smokeless-tobacco intervention - a subject that, conversely, the medical people, in general, had little interest.
Toward the end of my grant funding at OHSU, I went back into the research files to learn what is known about smokeless-tobacco cessation and found very little. Other than some studies done on histology and epidemiology, few researchers had anything to say about smokeless-tobacco cessation. Over the next year, I began compiling known data, including all the publications available from national organizations, state offices and federal resources, and tried to piece together the puzzle of smokeless-tobacco cessation. In so doing, I met others also interested in the problem and began a loose network of professionals with this common goal. Since 1989, our informal group has grown from about a dozen to over 8,000 health practitioners.
Most of the efforts of their network is focused on learning and sharing information about smokeless-tobacco cessation. They have a toll free number and web site with e-mail in order to continue coordinating ideas and programs among members.
Over the years, the network has set up alliances with many organizations who also are focused on oral health. Organizations such as the American Cancer Society, the National Institutes of Health, Oral Health America and the American Dental Association, just to name a few, all provide excellent materials that our network members use in their own programs. Other organizations like ASSIST and NSTEP also offer great suggestions. The difference is that we are working at the `grass-roots` level - in the practice with `wet-fingered` dentists and hygienists who are dealing directly with the patient. In this way, the network obtains a constant flow of information from the field which has been invaluable in giving current and updated suggestions to other professionals. Our information is just a little bit more `hands-on.`
Intervention vs. cessation
I find it is easier to try to prevent a person from ever using tobacco than trying to get him to quit once he has begun. However, some tobacco chewers, especially children and adolescents, don`t get the message about tobacco dangers until they are into their late teens, if at all. By that time they might have been chewing for five or 10 years. So a major goal of our network is to inspire health professionals, primarily those in the dental profession, to become skilled at intervention techniques for all ages.
In any practice, of those people using tobacco, maybe 10 percent want to quit right now and another 10 percent absolutely don`t want to quit. That leaves about 80 percent of patients who chew tobacco either thinking about quitting or don`t know. Intervention is the consistent, subtle messages we can give that may help people arrive at the conclusion that they want to quit. It seems logical that successes at cessation are better when the person wants to quit. Cessation, therefore, occurs after intervention.
Research suggests the success rate at tobacco cessation in a private practitioner`s office is somewhere around 5 percent. Does that mean that there is a 95 percent failure rate? Not necessarily. The person who receives the quit message may not, and probably won`t, quit immediately. But, he may get the same message from others like a nurse, his wife, friend or others and take time to think about what he was told. Eventually, after many intervention episodes, the patient may come to the conclusion that he/she wants to quit and often comes back to the dentist or hygienist for help in doing so.
I feel that health professionals should not grade themselves on how many people they can get to quit, but rather how many times they do give an intervention message when the opportunity arises. There is no reason not to have an intervention success approaching 100 percent. Since most of the patients who use tobacco fall into the category of `maybe quit,` doesn`t it make sense to concentrate most of our efforts in helping bring them to the conclusion that they want to quit? Once the patient admits he wants to quit, then the professional should be ready with suggestions.
The professional`s intervention
While about 75 percent of health providers think it is a good idea to tell patients about tobacco dangers, only about 10 percent routinely do so. Research shows that the reasons they don`t get involved are a combination of not feeling confident about the subject, questionable goals of doing so, afraid of a negative reaction from the patient, feel that the patient would be offended, there is not enough reimbursement to get into cessation or they just don`t have enough time. Network members are sensitive to these objections and have developed intervention-cessation techniques that not only don`t take up much time, but actually are fun and a positive experience for both the patient and the care-giver.
I believe that encouraging a person to never start using tobacco is the best prevention. Kids hear about chewing tobacco at an early age. Advertising, store displays, friends and even unknowing parents introduce smokeless tobacco to some kids as young as 3 to 9 years of age. By the time a child is 10, he may know what smokeless tobacco is but may not know what the dangers are. We have learned that when a health professional asks a child if he knows about, or even uses, smokeless tobacco, a golden intervention opportunity exists.
If we can identify that a child is using tobacco, there are many intervention opportunities available. The obvious one is to show him how evident it is that he chews tobacco by pointing out gum recession, tooth decay, leucoplakia or other histological effects caused by tobacco use and offering a brief message that he should quit. Brochures, videos or other information could be provided also, depending on the time available and reception of the patient for further information. Asking whether or not he knows how dangerous spit tobacco is often brings surprising results, for many don`t know that smokeless is dangerous.
If the patient doesn`t use tobacco, a professional can take a moment to congratulate him for non-use, tell him their own position on the use of tobacco, and solicit a promise from the patient that he will never use tobacco. If we can keep children away from tobacco until they are about 18, there is a very good chance that they will never use tobacco.
Some network members intervene with children as young as 6 years in order to get a jump on the tobacco industry. On each visit to the office, the child gets similar intervention messages. By the time they reach the `danger` period of 12 years of age, they already have had dozens of anti-tobacco messages. The influence of a health professional on the opinion and action of a young person is enormous.
Research shows that one of the main reasons young people start using tobacco is social pressures or imagery. Kids usually get their first `dip` from a friend or family member. By the time they go to the store to try to buy tobacco (or steal it since it is illegal for them to buy tobacco in most states if they are under 18 years), they may have already been using tobacco for several weeks. Shockingly, some kids have admitted they are willing to risk their health in order to have a "ring on their rear" or to just "fit in" with other young chewers. Trying to compete against this peer pressure or social imagery can be perplexing for some health advisors.
Why do people chew tobacco? A basic question, but one that I feel is critical if one is to help a tobacco chewer deal with the problem. We have learned from our members that there is no one way to help people quit chewing tobacco just as there is no one reason they chew. Like cigarettes, there seems to be the same three, main reasons for chewing: social/psychological, behavioral and physical or nicotine addiction.
Network members report that different social, cultural and behavioral influences have raised new challenges which may modify intervention and cessation techniques. What cessation method that works in one state or community may not work in another. A young chewer in North Carolina can have radically different needs than a chewer in Arizona.
In order to address all three aspects of the chewing behavior (physical, psychological and social) while at the same time being sensitive to the different cultural demands of various societies, members of the network have developed many different types of cessation programs that can be adopted. Having several ideas gives the practitioner more opportunities to intervene. A few methods used by network members are shown above.
Intervention as a practice-builder
Members of the network report that becoming involved with smokeless-tobacco intervention can be a good practice-builder. Practitioners offer help to people for a problem that is widespread and lacks conventional assistance. Quite often, the person asking for help is not the chewer, but rather a parent or friend who wants to get someone they know off tobacco. The network also gets dozens of e-mail messages each week from people who want to know how they can get a loved one away from smokeless.
Practices that let their community know that they are concerned and have possible solutions to this problem are doing great public relations. A poster we supply at no cost announces, `If You Chew Tobacco and Want To Quit, Ask Us, We Can Help!` Many practices have not only posted them in their clinics but also in places throughout the community such as on bulletin boards in grocery stores, churches, community centers and other locations. Not only do we see chewers respond for help, we see the decision-making mothers and wives of chewers come in. Some of these families become new patients.
Over the years, the network has enjoyed co-sponsoring displays in community events. The Oregon Mint Snuff Company has supported individuals, offices, clinics and entire dental societies with samples for a wide range of activities.
For two years in a row, Dan Laizure, DDS, and his staff in Walla Walla, Wash., have had an anti-tobacco booth at the local rodeo, just yards away from free giveaways by Copenhagen/Skoal person-nel.The event resulted in several media covering the story which ultimately brought the dental practice much positive recognition and several new patients.
Hundreds of health fairs go on each year by network members who receive support and materials from the network and from the Oregon Mint Snuff Company. Any practice wanting more information about the network can call (800) 938-1957, e-mail them at email@example.com, or visit the Web site at www.quittobacco.com.
7 ways to quit
- Quitting "cold turkey" - People can and do quit chewing on their own. Professionals can be very helpful by encouraging quitting and giving support whenever possible. There seems to be more success at quitting cold turkey by people who have just started to use smokeless tobacco (such as adolescents) and haven`t yet become addicted to nicotine.
- Direct substitution - Some patients have reported that they chew out of boredom or just "miss having something" in their mouth. With others, the desire is so strong, they are happy to have any help and can use the Mint Snuff while quitting tobacco altogether. For people who quit cold turkey then later feel they may relapse to tobacco, they can directly substitute Mint Snuff until the urge passes.
- Titration using decreasing amounts of tobacco - Some chewers who feel the effects of nicotine withdrawal have found it helpful to mix Mint Snuff with their tobacco in a ratio of 1:4 one week, 1:3 the following week, 1:2 the next, 1:1 afterwards and finally to straight Mint Snuff (or quit entirely).
- Alternating Mint Snuff dips with tobacco - Patients who use chewing tobacco find it easier to use Mint Snuff alternatively starting every other dip then gradually using Mint Snuff more and more until they don`t use tobacco any more.
- Use of nicotine patches alone - Chewers who display definite signs of nicotine withdrawal may want to consider the use of nicotine patches. They are urged to check the latest information on suggested levels and age criteria for the use of patches with smokeless-tobacco users.
- Use of nicotine patches with Mint Snuff - We have had many chewers who used the patch tell us that during their quit period they missed having the oral gratification. Some used Mint Snuff for that purpose while using the patch for nicotine-replacement therapy.
- Nicotine gum (Nicorette) - Studies have suggested that nicotine gum has not been very helpful in the cessation efforts. However, it is always worth a try if the patient wants to use it.
The minty alternative
Dealing with the social and behavioral aspects is tough. For kids who chew for social or image reasons, we can either try to convince them to quit "cold turkey" (which, for most of us, has not been overly successful) or we can offer an alternative that provides them the same social imagery and behavior, but is harmless. Some of these alternatives have been sunflower seeds, bubble gum and sugarless candy which, although somewhat acceptable, don`t offer the same perceived benefits as their chew.
Two products that have been tested by members of the network for over nine years, are safe, food grade products called Mint Snuff All Mint Chew and Mint Snuff Pouches produced by the Oregon Mint Snuff Company in Tillamook, Ore. (800-EAT-MINT; www.mintsnuff.com). These products are made from mint, not tobacco, and offer the same look, feel and behavior as tobacco.
By giving a chewer Mint Snuff, a professional is meeting the user "halfway" and providing a positive experience during the intervention phase. Naturally, we would rather the chewer didn`t do the behavior at all, but if he is going to anyway, we would rather he used safe mint. Members feel that the availability of an alternative greatly increases their success at not only developing new intervention opportunities but also at cessation.
But will an alternative on the market get young people to try it and go on to tobacco? I sincerely doubt it. First of all, Mint Snuff is only sold at the tobacco section and is not promoted in any way to young people other than when they visit the dentist. If a child goes into the store to buy smokeless tobacco, they will be staring right at dozens of cans of tobacco. Most kids come into the store already predisposed for tobacco use, most likely because they have already tried spit tobacco and now want to try to get their own. We hope Mint Snuff is going to be there right alongside tobacco for them to choose over tobacco.
For those people who think that this alternative, being a "look-alike" is going to draw them into tobacco use, I request they do some field testing on their own to see what is happening in the real world. Clearly, we have been shown that kids know the difference between tobacco and look-alikes. I think of Mint Snuff as I would decaffeinated coffee for coffee drinkers. It allows the behavior and social aspect without the ingredients that might cause harm. I can assure you without a doubt that the people in our network also agree with this philosophy.
From November 1996 through November 1997, the Oregon Mint Snuff Company sent out over 300,000 free cans of their products, as well as thousands of color posters and brochures, to participating members of the network. They also have awarded hundreds of promotional T-shirts that announce "Practice Safe Snuff" to clinics who have done exceptional work in smokeless-tobacco cessation.