2. • 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
2
3. Smokeless products deliver
much more nicotine;
dependence levels likely to
be high. Patient may use credit: Kevork Djansezian/Getty Images
more as it can be easily
concealed 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
3
4. 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
4
5. 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
5
11. Good things about Not so good things
using chew about using chew
Not so good things Good things about
about quitting chew quitting chew
Mayo Clinic: Your Path to Smokeless
Tobacco Freedom 11
12. 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.
12
14. After eating
Working or finishing a job
Driving
Drinking alcohol
Recreation
Watching sport events
Stress
Seeing someone else using
14
16. 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
16
17. 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.
17
18. (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.
18
19. • 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
19
20. 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
Mayo Clinic Guidelines
20
21. Available in 2 mg and 4 mg
Use 2 mg if also using patch
21
22. Available in 2 and 4 mg
Use 2 mg if using patch
Proper instructions Essential!
22
23. 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
23
24. 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
24
25. 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
25
26. 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
26
27. 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
27
28. 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?
28
29. 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
29
30. 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
30
32. 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
32
33. 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!
33
34. 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
34
35. 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?
35
36. 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).
http://www.nidcr.nih.gov/OralHealth/Topics/SmokelessTobacc
o/SmokelessTobaccoAGuideforQuitting.htm
36
37. Outstanding Guide: Order
from ETR Associates. Offers
bulk discounts.
Enough Snuff: A Guide for Quitting Smokeless Tobacco, Severson &
Gordon.
http://pub.etr.org/productdetails.aspx?id=100000132&itemno=A050
37
39. Catherine Whitworth, M.P.A., CTTS Donald R. Reed Jr., M.A. CTTS
West Virginia School of Public Health Southern Coalfields Tobacco Prevention
Prevention Research Center Coalition Network
Morgantown, WV Princeton, WV
cwhitworth@hsc.wvu.edu tobaccospecialist@strongcommunities.org
304-293-0926 304-320-9990 39
