Nature of Tobacco Addiction and Widthdrawal
Methods of Cessation
Effects of Cessation
Smoking Cessation and Weight Gain
Handling a Relapse
Although the use of smokeless tobacco ("dip," "chew," "snuff," "rub") has enjoyed a long history in the United States, recent years have witnessed a rapid increase in the use of these products. A national survey indicated that over twelve million Americans use some form of smokeless tobacco, and nearly half of these persons used smokeless tobacco at least once per week. In recent years, total sales of moist snuff products in the United States has increased approximately 55 percent.
A recent Surgeon General's report concluded that smokeless tobacco use can cause oral cancer and gum disease, as well as have other adverse health effects, e.g., peripheral vascular disease, delayed wound healing, and peptic ulcer disease.
The reasons why people use smokeless tobacco seem to parallel the reasons why people smoke: (1) it provides a sense of increased energy or stimulation; (2) it provides a pleasurable feeling which often accompanies a state of well-being; (3) it reduces tension or feelings of anxiety; and (4) it becomes automatic or addictive.
Although less systematic research has been conducted with smokeless tobacco users than with smokers, it is clear from the surveys that have been conducted that the majority of smokeless tobacco users would like to quit.
NATURE OF TOBACCO ADDICTION AND WITHDRAWAL
Quitting smokeless tobacco use can be very difficult, and many ex-chewers go through the quitting process several times before becoming long-term quitters.
People begin to dip or chew for a variety of reasons: pleasurable sensations, relaxing effect of nicotine, desire to appear more grown up or sophisticated, peer pressure from friends, etc. Over time, however, with day after day of tobacco use, dipping or chewing tobacco becomes a strongly ingrained habit that is difficult to give up: chewers become "hooked." It is useful to think of the tobacco habit as having two primary components: one physical and one psychological, although the distinction between the two is sometimes difficult to make. The physical aspect of addiction is a result of continued exposure to nicotine. All tobacco products contain substantial amounts of nicotine, a powerful drug, which acts in the brain and throughout the body. With each dip or chew, this powerful drug exerts its effects.
The pharmacologic and behavioral processes that determine nicotine/tobacco addiction are similar to those which determine addiction to other drugs. According to the U.S. Surgeon General's 1988 Report, nicotine is more addictive than any other drug, including cocaine, heroin, opium, and marijuana.
Nicotine exerts a wide variety of complex effects, but some of the more common effects are that it can help you to relax , help control your hunger, or make you feel more alert. Over time chewers become physically dependent on nicotine and need to use tobacco just to feel normal.
The second factor that helps maintain the habit is what psychologists call "conditioned association." After years of use, consistent patterns develop. For example, a person may find that he typically uses tobacco when driving, when hunting or fishing, when relaxing at home, or when feeling angry, or sad, etc. These patterns become strongly ingrained and the activities, thoughts, feelings, etc. that often accompany using tobacco become automatic "triggers" that elicit a craving for tobacco. If you have ever found yourself reaching "automatically" for a dip or chew, without thinking, or suddenly had a strong urge for a tobacco when you were in a setting where you normally dip or chew, you have experienced "conditioned craving." This is a very powerful effect which can make it difficult to quit and can cause a relapse, even years after quitting.
Because tobacco use is maintained both by nicotine addiction and conditioned habit, the most effective methods of cessation are those that attack both factors.
METHODS OF CESSATION
Research on smokeless tobacco cessation is in its infancy, and only a small number of studies have been conducted. For the most part these studies show that quitting smokeless tobacco is as difficult, or slightly more difficult, than quitting smoking, but it certainly can be done.
The vast majority of cessation programs available for smokeless tobacco users are offered as part of research-based studies at major universities or medical centers. There are a few pamphlets that provide guidelines on quitting available from major health organizations (e.g., the American Cancer Society); one commercially available self-help booklet ("Enough Snuff" available from Dr. Herb Severson at the Oregon Research Institute); and some smoking cessation programs allow smokeless users to join. However, unfortunately, in contrast with smoking cessation, there is not a large industry devoted to assisting smokeless tobacco users with quitting.
The only commercially available program developed expressly for smokeless tobacco users is the LifeSign Program for Dippers and Chewers. Click here for information on LifeSign.
Because of the paucity of available options, most smokeless tobacco users "go it alone" and simply try to quit cold turkey. Although many quitters do succeed by going cold turkey, many more fail because of withdrawal symptoms (e.g., irritability, frustration, anger, difficulty concentrating, increased appetite, and urges to dip or chew) and strong cravings that come from the tobacco use habit.
Some researchers have experimented with "nicotine replacement therapy" (using either nicotine chewing gum or nicotine transdermal patches). Both nicotine gum and transdermal nicotine patches provide doses of nicotine which provide relief from withdrawal symptoms while the tobacco user works on breaking his habit. Over time, the dose of nicotine is gradually reduced. Both the gum and patches have some fairly common side effects, and they are not appropriate for people with certain health problems. Side effects of gum use include dizziness, nausea and jaw muscle ache. There have also been rare cases of overdosing among smokers. At this point, there is little in the way of conclusive evidence that these methods are effective for smokeless tobacco cessation.
Many tobacco users find the concept of gradual cessation very appealing. It seems intuitively obvious that it would be easier to cut down a little bit every day, rather than to quit cold turkey. The good news is that this approach really does work. Recent research studies conducted under grants from the National Cancer Institute show that gradual cessation does work for smokeless tobacco users.
However, gradual quitting is not as simple as it sounds. It does not work very well to simply decrease the number of dips or chews per day. Although this approach does decrease nicotine intake, it does not weaken the conditioned habit. In fact, it may actually strengthen it.
The key to successful tobacco cessation is a concept called "scheduled, gradual reduction" (SGR). With SGR, tobacco users dip or chew on a time-based schedule, not whenever they want to have tobacco. Gradually, the time between dips or chews is increased until complete cessation is achieved. The time-based schedule forces smokers to disrupt their usual pattern, thus their habit is weakened. The increase in time between dips or chews results in less tobacco being used per day, and therefore nicotine intake is decreased.
Researchers at PICS, Inc., have developed a self-help program that implements the SGR method through the use of a tiny, hand-held computer (LifeSign). Click here for information on LifeSign.
EFFECTS OF CESSATION
A variety of symptoms, both physical and psychological, may be experienced after quitting smokeless tobacco abruptly (cold turkey). Most symptoms decrease sharply during the first few days of cessation and continue to decline gradually over the next two or three weeks. The most commonly reported withdrawal symptoms include: irritability (caused by the body's craving for nicotine); fatigue (may result from the fact that nicotine is a stimulant and cessation takes away that stimulation); insomnia; difficulty concentrating (from the lack of stimulation which nicotine provides to the brain); hunger (as a result of nicotine acting as a stimulant on the body's metabolic rate which causes the metabolic rate to slow when a person quits smoking); and craving for tobacco. These symptoms are most severe within the first two or three days after quitting. Gradual cessation can help reduce the frequency and severity of these symptoms.
TOBACCO CESSATION AND WEIGHT GAIN
Although there has been a great deal of research on weight gain following smoking cessation , very little research has been conducted in this area with smokeless tobacco users. Nicotine does speed up metabolism, so quitting smokeless tobacco use may result in a slight increase in weight.
To help limit weight gain after quitting, eat a well-balanced diet and avoid the excess calories in sugary and fatty foods; satisfy cravings for sweets by eating small pieces of fruit, have low-calorie foods on hand for nibbling, drink 6 to 8 glasses of water per day, and build exercise into your life by walking 30 minutes a day or doing the physical activity of their choice, such as running, cycling, swimming, or gardening.
HANDLING A RELAPSE
Former tobacco users start up again for any of several reasons - stress, withdrawal symptoms, alcohol, or boredom. One important lesson which chewers learn when quitting is that they can't test themselves by having a dip or two after quitting. If a relapse occurs, ex-chewers should not despair. A quitter should:
The long-term benefits of tobacco cessation include reduced risk for oral cancer and gum disease, as well as decreased risk of other systemic diseases such as peripheral vascular disease, delayed wound healing, and peptic ulcer disease. There are also some immediate benefits which include: (1) improved sense of taste; (2) better oral health; and (3) the effects of nicotine on pulse rate and blood pressure are eliminated within 20 minutes of the last dip or chew.
Note: Portions of this document were abstracted from "Cessation and Quitting published by Action on Smoking and Health (ASH), 2013 H Street, NW, Washington, DC 20006.
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