smokeless tobacco creating the quit plan 2012 catherine whitworth and donald reed

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• Assessing dependence and motivation • Preparation

• Setting a time frame • Reasons • Triggers • Environment

• Support • Behavioral • Family & social

• Specific strategies tailored to patient • Treating withdrawal • Tapering vs all at once

• Avoiding relapse

8 to 10 dips or chews a day is = smoking 30 to 40 cigarettes; holding an average dip or chew in the mouth for 30 minutes equivalent to 4 cigarettes

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Smokeless products deliver much more nicotine; dependence levels likely to be high. Patient may use more as it can be easily concealed

credit: Kevork Djansezian/Getty Images

Habitual & cultural behaviors are deeply entrenched ◦ Strong sense of

identity may be tied to smokeless use

◦ More activities linked to use

◦ Most initiate at a very young age, often introduced by family member

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Tapering off seems to work better for smokeless users than for smokers

Stronger need for oral substitutes ◦ Non-tobacco mimic products

◦ Sunflower seeds

◦ Cinnamon sticks

◦ Jerky

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Partnership to Assist with Cessation of Tobacco. www.makeapact.ca

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Rxforchange.ucsf.edu

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Mayo Clinic: Your Path to Smokeless Tobacco Freedom

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Mayo Clinic: Your Path to Smokeless Tobacco Freedom

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Importance

0 1 2 3 4 5 6 7 8 9 10

Confidence

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Good things about

using chew

Not so good things

about using chew

Not so good things

about quitting chew

Good things about

quitting chew

Mayo Clinic: Your Path to Smokeless Tobacco Freedom

Two to three weeks in advance. This time is needed to prepare.

Midnight on a Thursday or Friday works well

for most people. Avoid selecting a day that will be especially

stressful. Schedule a doctor or dentist visit if this is

an option, especially if using any medication.

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After eating

Working or finishing a job

Driving

Drinking alcohol

Recreation

Watching sport events

Stress

Seeing someone else using

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Get active, take a walk, work out, ask the dog for help

Use a short acting NRT

Drink water

Chew strong gum, toothpicks, cinnamon sticks, mints, a substitute product

Call a friend - be with people who don’t dip

Take your work break in a different place

Take a different route to work

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7 Approved Medicines for nicotine dependence, some by Rx, some OTC.

Only the patient and clinician can decide what is most appropriate for the individual but try to dispel myths.

Combination NRT therapy is safe and effective for smokeless users.

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(NRT) can ease symptoms of nicotine withdrawal.

A heavily addicted patient will benefit from

more aggressive dose – combination therapy.

Delivery systems: patches, lozenges, gum,

nasal spray, puff inhaler. Provide instructions.

Much more effective when used with a

behavioral support.

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• Worn on the skin between the neck and the waist, and provide a steady delivery of nicotine to increase patient comfort

• Can be started while tapering down when the patient notices withdrawal symptoms

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24 hour nicotine patch: >3 cans or pouches/week = 42 mg/day 2-3 cans or pouches/week = 21 mg/day <2 cans or pouches/week = 14 mg/day Adjust based on withdrawal symptoms,

urges, and comfort. After 4-6 weeks of abstinence, taper every 2-4 weeks in 7-14 mg steps as tolerated

Combination Therapy: Patient may add 2 mg lozenge or gum as needed for acute cravings

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Mayo Clinic Guidelines

Available in 2 mg and 4 mg Use 2 mg if also using patch

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Available in 2 and 4 mg

Use 2 mg if using patch

Proper instructions Essential!

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Bupropion (Zyban - Wellbutrin) ◦ Antidepressant that that has been helpful in

treating nicotine addiction ◦ Can be used with NRT ◦ Helpful for those concerned with weight gain

Chantix ◦ Pfizer medication used solely to treat nicotine

addiction ◦ Blocks nicotine's connection to dopamine receptors,

making tobacco less desirable. ◦ Treats effects of cravings and withdrawal. ◦ Kidney Issues ◦ Mental Health Concerns

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Herb based non-tobacco chew products processed to mimic taste and texture of smokeless tobacco

Can be effective in gradually reducing level of nicotine while allowing user to continue habit

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Substitute product is blended with tobacco user is accustomed to and kept in tobacco can

10% product with 90% tobacco first week

Increase ratio by 10% each week

Some programs endorse partner managing the system

NRT is optional. Safe to initiate when withdrawal symptoms begin. Patient can adjust for comfort

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GOLDEN EAGLE Herbal Chew Flavors: Straight, Wintergreen, Cinnamon, Hibiscus-Ginger, and Licorice Mint 1-800-736-8749 www.goldeneaglechew.com SMOKEY MOUNTAIN Herbal Chew Flavors: Cherry, Classic, Cinnamon Ice, Arctic Mint, Arctic Mint Pouches, Wintergreen, and Wintergreen Pouches 1-800-762-2439 www.smokeymountainsnuff.com YOUNG'S Herbal Chew Flavors: Classic, Wintergreen, Licorice, and Ginger Red 928-632-7272 www.youngschew.com BACC OFF Flavors: Straight, Wintergreen, Extra Wintergreen, Mint, Mint Pouches, Straight Pouches, and Wintergreen Pouches 1-800-866-2439 www.dipstop.com

From others ◦ Tell people about your quit date ◦ Ask them to support you ◦ Tell them how

Get coaching from a quit line, support group, web networking or other program ◦ Tobacco Quit line 1-800-QUIT-NOW

Most cessation product companies offer a

support program

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Physical Activity is not only is a natural stress reliever but can help prevent the weight gain some people experience

Help the patient reframe – what is perceived as stress is often physical withdrawal

If I dip, will this stressor actually go away?

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Choose one or more activities to do without tobacco

Schedule tobacco use “on the clock”

Use the same amount, but change the setting in which the product is used

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Get rid of all smokeless tobacco and empty cans/pouches

Remove any reminders

Put together a survival kit

Try to get relief from some responsibilities and stressors just for a few days

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Irritability Feeling tired Difficulty sleeping Constipation Depressed mood Headache Trouble concentrating Strong Urges

Ask the patient how he will cope, and what others can do to help him. He knows himself best. Make suggestions only if necessary

Encourage him to do whatever it takes ◦ Eat whatever he wants for 1st three days – weight

control can wait ◦ Remember the gum, jerky, carrots, substitute

products ◦ Sleep as much as much as he wants or stay busy!

The withdrawal symptoms WILL lesson. Urges will come less often and will not last as long after the first week

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Know potential triggers in advance and plan for them

Drink plenty of water Get enough sleep. Changing

behavior is easier when well rested Don’t try to fix everything at once However, watch out for alcohol Increase physical activity!

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Put yourself first. Quitting is the best thing you can do for your family. Accept help

Plan rewards for milestones

Focus on the present

◦ Handle one urge at a time

◦ If you slip, it’s not over. Forgive yourself

◦ Ask what happened & why

◦ Get back on track with

the next urge

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Quitting and staying quit are two separate challenges

Lapse (slip) vs relapse. Mistaken beliefs.

Continue to use medicines until you have NO URGE TO USE.

After short term coping skills, the key is lifestyle change. Replace the tobacco with something better. Forever.

If I resume chewing, will it change the outcome of this life event?

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http://www.nidcr.nih.gov/OralHealth/Topics/SmokelessTobacco/SmokelessTobaccoAGuideforQuitting.htm

Free Quit Plan Guides available from National Institute of Dental and Cranial Research (NIDCR)

Recommend crossing out “What About Medication” statement on page 13. (anti-NRT and outdated).

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Enough Snuff: A Guide for Quitting Smokeless Tobacco, Severson & Gordon. http://pub.etr.org/productdetails.aspx?id=100000132&itemno=A050

Outstanding Guide: Order from ETR Associates. Offers bulk discounts.

Mylastdip.com Killthecan.org Quitnet.com Quitsmokeless.org ucanquit2.org (Quit Tobacco – Make Everyone Proud

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Catherine Whitworth, M.P.A., CTTS West Virginia School of Public Health Prevention Research Center Morgantown, WV cwhitworth@hsc.wvu.edu 304-293-0926

Donald R. Reed Jr., M.A. CTTS Southern Coalfields Tobacco Prevention Coalition Network Princeton, WV tobaccospecialist@strongcommunities.org 304-320-9990