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Kicking the can: Smokeless tobacco often overlooked but also hard to quit

Dave Wallis / The Forum

North Dakota State University pharmacy student Paul Jilek said three years into his education, he's already learned plenty about helping people give up smoking. But he said that same level of focus doesn't seem to apply to all forms of tobacco, despite the health risks and addictive properties they all have whether inhaled through a cigarette or absorbed through a dip of chew. "We're taught about how to help people with smoking and smoking cessation, but nobody really touches on smokeless tobacco cessation," he said.

There are plenty of tools designed to help quit smoking, with nicotine patches, gums and lozenges offering suggested dosages depending on how many cigarettes a person uses each day to offset withdrawal. But those products don't include guidelines for smokeless tobacco users, and Jilek and classmate Mike Fisher decided to do something about it. For a research project they'll present at a pharmacists meeting hosted by NDSU next month, the two crunched the numbers and came up with their own suggested dosages that pharmacists and physicians can use to help their patients kick the can.

Fisher said the dangers of smoking seem to be getting across to young people, and local and national trends show the country is starting to get a grip on smoking rates. But that's not the case with chewing tobacco, snuff, snus and the other smokeless tobacco products that often are marketed to young men as a safer alternative to cigarettes. "I don't personally have friends that smoke, but I have a lot of friends that chew," he said. "That's why we took this approach." A CHEWING PROBLEM Jilek said smokeless tobacco is less dangerous than cigarettes, especially because it doesn't pose the same respiratory risks. But both contain nitrosamines, a key carcinogen in tobacco, and an average dip held in the mouth for 30 minutes packs the nicotine equivalent of three cigarettes.

"It's not like a healthy alternative to smoking," he said. "You still have a lot of the cancer risks, especially in the mouth and the esophagus, and it runs with all the dental problems, too." And Holly Scott, tobacco prevention coordinator with Fargo Cass Public Health, said statewide surveys show the use of smokeless tobacco still is a concern among middle school and high school students. According to the voluntary and anonymous Youth Risk Behavior Survey conducted every other year, about 15.1 percent of high school students in the state reported using chew, snuff or dip in the past 30 days in 1999. North Dakota saw a "pretty steady decline" in the years since, Scott said, but that usage jumped back up to 15.3 percent in 2009 and 13.6 percent in 2011.

That's a stark contrast to what the state is seeing with cigarette use, with 19.4 percent of high schoolers saying they had smoked within the past 30 days in 2011 - a big drop from the 40.6 percent who reported doing so in 1999.

In 2011, North Dakota had the country's fifth-highest rate of youth using smokeless tobacco, behind only Kentucky, Wyoming, South Dakota and West Virginia and well above the national average of 7.7 percent.

Youth aren't the only ones reaching for a can here, with the Centers for Disease Control and Prevention reporting 6.6 percent of those over 18 in the state used chew in 2009 - nearly twice the national average.

Other recent studies show smokeless tobacco use is on the rise across the country, especially among young men ages 18 to 24, who the CDC says are the most common users.

Fisher said those national trends suggest the local rate could rise even more, especially as booming oil development in western North Dakota draws new workers and lures young men from the Fargo area to the Oil Patch.

"We look at what's going on in the western side of the state, and I've had numerous friends work out there," he said. "Just about all the guys I see that go spend some time out in the oil fields come back smoking or chewing."


Jilek said North Dakota and other Midwestern states may see more smokeless tobacco usage because of their "cowboy background" and clever marketing tactics that pitch chew as the tobacco of choice for athletes and strong, masculine men. Pharmacy associate professor Mark A. Strand said another factor may be tobacco companies regrouping after the 1998 tobacco settlements and harsh restrictions for marketing cigarettes. Instead, he said, many companies have released new products such as cherry-flavored smokeless tobacco, dissolvable nicotine "orbs" and toothpicks with nicotine in them that are easy to conceal and use.

"There hasn't been a norm in our society yet that sees smokeless tobacco in sort of a negative light," he said. "It's still kind of glamorized by athletes and cowboys and country-western singers, and the tobacco companies are taking advantage of that." Strand said teenagers and young men that experiment with smokeless tobacco don't intend to become lifelong users. But, like with smoking, many will become addicted and be stuck with a bad habit. Jilek said the goal of their research was to make people aware that there is a problem with smokeless tobacco, both across the country and at an even higher rate in North Dakota.

Strand said their work resulted in "innovative" tools to help pharmacists give advice to smokeless tobacco users who want to quit. The report they'll present next month includes both basic quit plan guidelines, such as tapering off tobacco and setting a realistic quit date, as well as a table suggesting the dosage of nicotine gum, lozenges, patches or prescription medications users may want to try depending on their habits.

"If you go to a box of Nicorette gum and you look on there, most of the time they don't have the equivalencies for chewing tobacco; they have them for cigarettes," Jilek said. "That's something we wanted to put together so that they would know what to recommend."

Strand said the work is more than just good experience for these future pharmacists - it's also a way of addressing a problem that's largely affecting young men around the same age as Jilek and Fisher.

Fisher said it's a new tool that he can put to use when he starts his professional career, helping his peers make a healthy decision to kick the can and get off nicotine, whether it's through a cigarette or a flavored pouch.

"If this helps both medical professionals and the people looking for the options themselves, that's kind of our goal is to get that information out there," he said.

Scott said education efforts can't keep up with the funding tobacco companies spend to push their products, including the growing number of smokeless tobacco options, and more work is needed to remind residents just how dangerous any form of tobacco can be. "We're not going to see our numbers drop to 0 percent tomorrow," Scott said. "It takes a certain amount of time, but education combined with enforcement of policy and encouraging people to quit, it's all of those things working collaboratively together. So, yeah, we're absolutely on the right path." For help with quitting tobacco, contact your pharmacist or physician or call 1-800-QUITNOW. Developing a successful quit plan • First, YOU have to decide you are GOING to quit. • Focus on the adverse effects of chewing and establish your reasons for quitting.

• Recognize the stigma society places on people who use chewing tobacco, using it as motivation to quit. • Set a realistic quit date and don't try to do too much too fast. • Taper yourself off smokeless tobacco. This increases quitting success rates and helps avoid nicotine withdrawals. • Leave your tin behind and instead carry oral substitutes such as gum, hard candy, sunflower seeds or mint leaf snuff. • Ask your pharmacist or physician if you would benefit from nicotine patches, lozenges, gum or prescription medications. • Ask friends or co-workers who have successfully quit chewing for tips. Find out what worked for them, and use strategies you believe could help you.

• Develop a support group. Let your family, friends and co-workers know you are going to quit and that you might act a little different over the next couple of weeks.

Source: Mike Fisher and Paul Jilek, adapted from the Theory of Reasoned Action