Partners in Quitting

The use of moist snuff gained popularity in the 1970s with marketing targeted to young adult males. Since then, moist snuff continues to represent a growth segment of the domestic tobacco marketplace in the United States. According to SAMHSA's 2000 National Household Survey on Drug Abuse, an estimated 7.6 million Americans aged 12 and older (3.4%) had used smokeless tobacco (snuff and chewing tobacco) in the past month, with such use most common among young adults aged 18 to 25. Men were 10 times more likely than women to report using smokeless tobacco (6.5% of men aged 12 and older compared with 0.5% of women). There is a vast amount of epidemiological evidence linking the use of moist snuff and chewing tobacco with adverse health outcomes, particularly cancer of the oral cavity, including cancer of the lip, tongue, cheeks, gums, and the floor and roof of the mouth. Other effects of smokeless tobacco use include addiction to nicotine, oral leukoplakia (white mouth lesions that can become cancerous), gum disease, and gum recession. Possible increased risks for heart disease, diabetes, and reproductive problems are being studied.  There have been few published studies with a focus on quitting snuff, particularly regarding the application of brief cognitive-behavioral interventions for snuff cessation in nonclinical settings.

The Partners in Quitting program consists of a smokeless tobacco self-help manual, "Enough Snuff: A Guide for Quitting Smokeless Tobacco", which was designed to be used as either a supplement to group counseling or for individual cessation. In addition to this manual, participants receive up to four proactive counseling telephone calls designed to assist them in making a quit attempt. The telephone counseling protocol was established to place emphasis on the early stages of quitting to offset the potential for relapse. The initial call is placed within 4 days of a self-help manual being mailed and is designed to encourage setting a quit date. Subsequent calls are negotiated and made with permission of the participant. The calls place an emphasis on support, problem-solving, and the use of cognitive-behavioral strategies, including monitoring tobacco behavior patterns, goal-setting, finding alternative coping options, and planning for high-risk situations or cues associated with tobacco use. Calls are made by health educators with experience providing telephone cessation support for smokers. 

The program is administered by health educators who have experience providing telephone cessation support for smokers. These health educators should also receive an additional 4 hours of training specific to moist snuff and chewing tobacco to increase their skills.

The intended audience for this program is adult male users of moist snuff or chewing tobacco.

The program can be implemented in the individual's home.

Required resources include the 60-page self-help manual, "Enough Snuff: A Guide for Quitting Smokeless Tobacco" and up to four supportive phone calls from health educators who have experience providing telephone cessation support for smokers. Costs associated with the program's implementation are not provided.

Potential subjects were recruited during a 12-month period using strategies designed to reach moist snuff users who were either community members or members of a large nonprofit health plan located in Minnesota. The study was open to male users of moist snuff or chewing tobacco who were older than 18, had used moist snuff or chewing tobacco for 6 months, were not using other tobacco products regularly, and were not in treatment for substance abuse. Of the 421 study packets mailed to eligible tobacco users, 221 participants returned baseline surveys and were randomized to the telephone counseling (n=109) or a quitting-manual-only comparison group (n=112). The average age was 35.7 years. 

Participants were contacted by mail at baseline, 3 months post-randomization, and 6 months post-randomization to complete a self-report questionnaire. Telephone contact was made with non-responders (approximately 40% of the sample) to encourage completion of the questionnaire. Participants were asked (1) whether they currently used smokeless tobacco (chew or snuff); (2) whether they had used any smokeless tobacco in the last 7 days; and (3) whether during the last 7 days they had "smoked cigarettes regularly", "smoked cigarettes once in a while", or had "not smoked cigarettes at all, not even a puff". Moist snuff users were considered abstinent if they reported they had quit snuff and had not used any in the past 7 days and they had not smoked tobacco in the past 7 days. 

• Using an intent-to-treat analysis where those who did not complete the follow-up surveys were considered to be continued users, 25% of those in the manual-only group quit tobacco at 6 months compared to 40.4% in the manual-plus-telephone counseling group (p<.001). 
• A significant dose response relationship was found between the number of calls and the likelihood of quitting tobacco at 3 months (p<.015). However, this effect was no longer significant at 6 months.