Public Health Perspectives

smokeless tobacco use by American males, there has been little research on assisting users to quit. A review of research shows promising results by adapting smoking cessation procedures. A review of clinical cessation studies and psychosocial studies provides support for development and assessment of ST cessation clinical and self-help programs. Distinctive aspects of ST cessation include the high prevalence of oral lesions, need for an oral substitute during withdrawal, the potential use of nicotine polacrilex as an adjunct, perception of ST as a safe alternative to smoking, frequent use of both cigarettes and ST, and difficulty in using nicotinefading approaches. Specific components and measures involved in ST cessation are reviewed. Support for public health interventions is provided by a recent study of ST cessation in HMO dental clinics that demonstrated the efficacy of providing ST users advice to quit in the context of health care delivery. Cessation materials have also been developed for special populations, such as Native Americans and baseball players. INTRODUCTION Over the past 6 yr, there has been a great deal of public interest in and scientific attention to the detrimental health effects of smokeless tobacco use. The publication of the Surgeon General’s report on ST use (US DHHS, 1986a) and the publicity surrounding the NIH Consensus Development Conference on Smokeless Tobacco (US DHHS, 1986b) focused attention on these health concerns. These publications identified three major health risks associated with the oral use of tobacco: oral cancer, development of leukoplakia and other oral health problems, and nicotine addiction. These two documents increased public awareness and spurred Congress to pass House Bill 99-252, the Smokeless Tobacco Act of 1986. This act instituted rotating health warnings on ST products and eliminated radio and television ads for ST. Although the focus on ST increased public awareness of health effects, the sales of ST products have increased steadily with only a minor flat spot in the growth curve following the enactment of Public Law 99-252. Because the majority of new users of ST products are young teen males, recent research programs have focused on preventing young people from taking up the use of snuff or chew through school-based prevention programs (Severson and Zoref, 1991). Despite these educational efforts, the use of ST, especially moist snuff, is increasing, especially among male adolescents and young male adults (US DHHS, 1986a). As of 1986, there were already an estimated 6 million regular users of ST in the United States (US DHHS, 1986a). Unfortunately, there has been little effort toward assisting current users in quitting their habitual use of snuff or chewing tobacco. Despite the concern for potential negative health consequences, scientific study of ST cessation has lagged behind epidemiological, health, and preventive efforts. To date, there are few published studies on ST cessation, although several are currently in progress. Smoking and Tobacco Control Monograph No. 2 280 This paper broadly reviews the field of smokeless tobacco cessation. Published and unpublished studies are reviewed to provide a current assessment of ST cessation and guide future studies. Psychosocial studies that provide information on ST use and can guide development and implementation of effective cessation programs are also considered. The paper concludes with a review of ongoing public health interventions that provide direction on development of broad-based efforts to promote ST cessation. CLINICAL ST CESSATION STUDIES Although they are not well-controlled randomized clinical trials, they are instructive. The first published study of ST cessation was done by Glover (1986) who adapted the American Cancer Society’s FreshStart Adult Smoking Cessation Program for use with 41 adult ST users. He reported a 6-mo abstinence rate of only 2.3 percent. However, these subjects were mandated to attend the program, as they had been found in violation of school rules at a college that prohibited the use of tobacco products. Given the nonvoluntary nature of the subject sample, it is not unexpected to find a low success rate in cessation. Subsequent studies by Eakin and coworkers (1989) and DiLorenzo and coworkers (1991) provide a more optimistic view of the potential cessation rates that can be achieved by formal ST cessation treatment. Eakin and coworkers (1989) reported an intervention with adolescent daily users, aged 14 to 18, who were recruited by referrals from counselors, coaches, and teachers in Eugene, Oregon, high schools. The study had 25 chronic ST users with a quasi-experimental design in which 11 of the 25 subjects provided a comparison group by receiving delayed treatment (3-wk delay). This behavioral treatment consisted of three 1-h small-group meetings led by counselors. The multiple-component treatment was cognitive-behavioral in nature and focused on encouraging subjects to use coping skills for cessation. Of the 21 subjects completing treatment, 9 were successful in quitting their ST use at the end of treatment. Self-reported quitting was confirmed with saliva cotinine assessment, and subjects were followed up at 6 mo after treatment. Long-term cessation rates were reduced to 12 percent at 6-mo followup; however, subjects not achieving abstinence had a self-reported reduction of 45 percent in their daily use of ST from baseline levels. The participants in this study who quit reported that, in addition to the group sessions, the ongoing telephone calls and support by the counselor were key elements in their success. DiLorenzo and associates (1991) reported a multiple baseline design intervention on nine adult males recruited for a behavioral ST cessation program. Mean age of the subjects was 32 yr and the average length of use of ST was 9.3 yr. Seven subjects completed the eight 1-h behavioral treatment sessions provided over a period of 7 wk in small groups of three subjects each. Cue extinction, setting a target date for quitting, the use of a buddy system, and relapse prevention were the primary components of the Currently, there are only three published cessation studies involving smokeless tobacco. Unfortunately, these studies had relatively small samples and could be best characterized as pilot clinical research.