Not a safe alternative

Many terms are used to describe smokeless tobacco products, such as oral, chewing, snuff, spit, and spitless tobacco. All forms of oral tobacco contain chemicals known to cause cancer (carcinogens). These products can cause cancer of the mouth, pancreas, and esophagus (the tube that carries food from the mouth to the stomach). Oral and smokeless tobacco also cause many other health problems, such as gum disease, destruction of the bone sockets around the teeth, and tooth loss. They cause bad breath and stained teeth, too.

Smokeless tobacco is less lethal than cigarettes, but using any form of tobacco poses serious health risks. Here we will describe smokeless tobacco products and how they are used. We will also outline some of the health problems linked to smokeless tobacco use and how these tobacco products are marketed.

Smokeless tobacco facts

What is smokeless tobacco?

Smokeless tobacco comes in 2 basic forms, snuff and chewing tobacco. Several other forms of smokeless tobacco are also on the market.

Snuff is finely ground tobacco packaged in cans or pouches. It is sold in 2 forms: dry and moist. Moist snuff is used by placing a "pinch," "dip," "lipper," or "quid," between the lower lip or cheek and gum. Nicotine is absorbed through the tissues of the mouth. Moist snuff is also available in small, teabag-like pouches or sachets that can be placed between the cheek and gum. These are designed to be both "smoke-free" and "spit-free" and are marketed as a discreet way to use tobacco. Dry snuff is sold in a powdered form and is used by sniffing or inhaling the dry snuff powder up the nose.

Chewing tobacco comes in the form of long strands of loose leaves, plugs, or twists of tobacco. Portions of this, commonly called "plugs," "wads," or "chew," are chewed or placed between the cheek and gum or teeth. Nicotine is absorbed through the mouth tissues. The user spits out the brown juice – saliva that soaked through the tobacco.

Alternative smokeless tobacco products come in many forms. Snus (sounds like "snoose") is a form of moist snuff commonly used in Sweden and Norway. It is now being marketed in the United States. It is made of air-cured tobacco, water, salt, and flavorings. It has less tobacco-specific nitrosamines than most smokeless products used in the US because the tobacco is not fermented. (Tobacco-specific nitrosamines are chemicals known to cause cancer.) Snus is most commonly packaged in small pouches, but can also be used like loose moist snuff. A 2004 study showed that people who switch to Swedish snus have smaller amounts of certain cancer-causing agents in their bodies than those who use the more common smokeless products. But those who used snus still had notably higher levels of these cancer-causing agents than people who used nicotine replacement patches. Other smokeless products can be bought in the United States. These include pouches of snuff marketed as being low in nitrosamines, such as Exalt^® or Revel,^® and tobacco lozenges like Ariva^® and Stonewall^®.

Marketing of smokeless tobacco products

Tobacco companies have responded to the popular laws that ban smoking in public places by making and selling smokeless products that can be used in no-smoking settings. They use ad slogans such as "Anytime. Anywhere" and "No Smoking, No Problem" to target smokers who crave nicotine while in smoke-free settings. Free samples and coupons are also offered to encourage people to try these new products as a less dangerous alternative to smoking. Without smokeless products, these smokers might be motivated to quit smoking completely.

The tobacco industry is also promoting the idea that switching to smokeless products is an effective way to quit smoking. These claims are implied rather than stated outright, to avoid having these products regulated as drugs. There is no proven evidence that smokeless tobacco products can actually help smokers quit. Because these products contain tobacco, they are not required to be tested to be sure they meet Food and Drug Administration (FDA) standards. This is not the case with proven treatments for tobacco addiction, such as nicotine replacement products, antidepressants, nicotine receptor blockers, and behavioral therapies. These standard treatments have been carefully tested and have been proven to help people quit smoking.

There are 2 serious problems with the way smokeless tobacco is now marketed. The first is that their ads encourage smokers to use these products to meet their nicotine cravings in settings where they cannot smoke. This wipes out one of the benefits of smoke-free laws. Smokers who delay quitting by using smokeless products while continuing to smoke increase their risk of lung cancer. How long a person smokes is by far the most important factor in lung cancer risk.

The second problem from uncontrolled marketing of these products is that it may worsen the problem of tobacco use among teenagers. The last time US tobacco companies aggressively promoted smokeless products, there was a large increase in the use of moist snuff among teenagers, especially male teens. But very few smokers switched to smokeless – the big increase was in new users of tobacco.

What are the risks of using smokeless tobacco?

Smokeless tobacco products are not a safe substitute for tobacco smoking. Harmful health effects include:

• oral (mouth) cancer
• pancreatic cancer
• addiction to nicotine
• leukoplakia (white sores in the mouth that can become cancer)
• receding gums (gums slowly shrink away from around the teeth)
• bone loss around the roots of the teeth
• abrasion (scratching and wearing down) of teeth
• tooth loss
• stained teeth
• bad breath

Leukoplakia is a white sore or patch in the mouth that can become cancerous. Study after study has found high rates of leukoplakia at the place in the mouth where users place the "chew." One study found that almost 3 out of 4 of daily users of moist snuff and chewing tobacco had non-cancerous or pre-cancerous lesions (sores) in the mouth. The longer you use oral tobacco, the more likely you are to have leukoplakia.

Many regular smokeless tobacco users have receding gums and bone loss around the teeth. The surface of the tooth root may be exposed where gums have shrunk back. Tobacco can irritate or destroy the gum tissue. All this can cause teeth to loosen and fall out.

Smokeless tobacco may also play a role in heart disease and high blood pressure. Men who switched from cigarettes to snuff or chewing tobacco in a large American Cancer Society study had higher death rates from heart disease, stroke, cancer of the mouth and lung, and all causes of death combined than former smokers who stopped using all tobacco products. It is unclear whether the heart disease was caused by the smokeless tobacco products in this study, because there have been few large, long-term studies to identify all of the health problems caused by these products.

The snuff and chewing tobacco products most widely used in the United States have very high levels of cancer-causing agents called tobacco-specific nitrosamines. These carcinogens (cancer-causing agents) cause lung cancer in animals, even when injected.

How do the risks of using smokeless tobacco compare with cigarette smoking?

Smokeless tobacco products are less lethal than cigarettes. Even though they are marketed as a less harmful alternative to smoking, these products have not been proven to help smokers quit. Smokers who delay quitting by using smokeless products between cigarettes greatly increase their risk of lung cancer. They also set themselves up for new health problems caused by smokeless tobacco.

Who uses smokeless tobacco?

The 2004 data from the US Centers for Disease Control and Prevention (CDC) showed that among adults aged 18 and older, about 3% of people (6% of men and less than 1% of women) were current users of smokeless tobacco.

But rates among young people are higher. According to the CDC's 2007 survey, more than 13% of male high school students and 2% of female high school students were using smokeless tobacco. The CDC 2006 Youth Tobacco Survey reported that, of middle school students, 4% of the boys and 1% of the girls reported using smokeless tobacco at least once in the 30 days before the survey. Teens who use smokeless tobacco are more likely to smoke later.

Certain factors seem to be linked to whether or not young people will use tobacco. They include:

• peer pressure
• local lifestyles and fashions
• general attitudes toward authority
• economic conditions
• examples set by teachers and school staff
• presence of gangs
• use of illegal drugs and alcohol

In 2003, more than 1 in 3 major league baseball players used smokeless tobacco, mainly moist snuff. Athletes are the largest marketing source for smokeless tobacco, and are often seen on TV using it during a game. They have a lot of influence as negative role models for youth.

A more recent influence on the use of smokeless tobacco is the smoking bans many states are now enforcing. In light of these bans, tobacco companies are putting new marketing emphasis on their smokeless tobacco products. New smokeless tobacco products are being advertised as alternatives to cigarettes in places where smoking is not allowed. When smokers use these products as substitutes instead of trying to quit, it supports the tobacco industry.

Smokers who postpone quitting by using smokeless tobacco or oral tobacco products for a nicotine fix while in smoke-free settings do not decrease their lung cancer risk. They are still using tobacco and still smoking cigarettes. Lung cancer risk is affected most by how long a person smokes.

Quitting smokeless tobacco

Quitting smokeless tobacco is not easy, but you can do it. To have the best chance of quitting and staying quit, you need to know what you're up against, what your options are, and where to go for help. You'll find this information here.

Why is it so hard to quit?

Nicotine

It is hard to quit because nicotine, a drug found naturally in tobacco, is highly addictive. In fact, it is as addictive as heroin or cocaine. Over time, users become physically and psychologically dependent on nicotine. Studies have shown that they must deal with both of these dependencies to quit and stay quit.

Where nicotine goes and how long it stays: Nicotine enters the bloodstream from the mouth and is carried throughout the body. It affects many parts of the body, including your heart and blood vessels, your hormones, your metabolism, and your brain. During pregnancy, nicotine freely crosses the placenta. Nicotine has been found in amniotic fluid and the umbilical cord blood of newborn infants.

Many different factors can affect how quickly the body gets rid of nicotine. A regular oral tobacco user will probably have nicotine or its by-products, such as cotinine, in his body for about 3 or 4 days after stopping.

How nicotine hooks smokers: Nicotine causes pleasurable feelings that make the tobacco user want to use more. It also acts as a kind of depressant by interfering with the flow of information between nerve cells. As the nervous system adapts to nicotine, tobacco users tend to increase the amount of tobacco they use. This raises the amount of nicotine in their blood, as more tobacco must be used to get the same effect. This is called tolerance. Over time, the tobacco user reaches a certain nicotine level and then keeps up the usage to stay at this level of nicotine.

Smokeless tobacco delivers a high dose of nicotine. An average dose from snuff is 3.6 milligrams (mg) and from chewing tobacco is 4.5 mg – compared to 1 to 2 mg from one cigarette. Despite this difference, blood levels of nicotine throughout the day are much the same among smokers and those who use smokeless tobacco.

Nicotine withdrawal: Stopping or cutting back on smokeless tobacco use causes symptoms of nicotine withdrawal that are much like those smokers get when they quit. In a Swedish study, oral snuff users reported having as much trouble giving up tobacco as cigarette smokers did trying to quit smoking. Studies also suggest that when regular snuff users can't use snuff, they will smoke cigarettes or use another form of tobacco to satisfy their need for nicotine.

Withdrawal from nicotine is both physical and mental. Physically, the body is reacting to the absence of nicotine. Mentally and emotionally, the user is faced with giving up a habit, which calls for a major change in behavior. Both must be dealt with to quit and stay quit.

If a person has used tobacco regularly for a few weeks or longer and suddenly stops or greatly reduces the amount used, withdrawal symptoms start. These symptoms usually start within a few hours of the last dip or chew and peak about 2 to 3 days later. Withdrawal symptoms can last from a few days to up to several weeks.

Withdrawal symptoms can include any of the following:

• dizziness (which may last only 1 or 2 days after quitting)
• depression
• feelings of frustration, impatience, and anger
• anxiety
• irritability
• trouble sleeping (including trouble falling asleep and staying asleep, and having bad dreams or even nightmares)
• trouble concentrating
• restlessness
• headaches
• tiredness
• increased appetite

These uncomfortable feelings can lead you to start using tobacco again to boost blood levels of nicotine and stop symptoms. For information on coping with withdrawal, please see the section "How to quit."

Why quit?

There are many reasons to stick it out through withdrawal and quit using smokeless tobacco for good. Health reasons, as mentioned earlier, are the obvious ones. But consider the following as well.

Social acceptance

Chewing and dipping carry a heavy social price, especially when dating. Bad breath, gum disease, and stained teeth are very unappealing. The spitting required by most smokeless tobacco is not pretty, either.

Cost

A tobacco habit can be costly. It isn't hard to figure out how much you spend on tobacco: multiply how much money you spend on tobacco each day by 365 (days a year). The amount may surprise you. Now multiply that by the number of years you have been using tobacco and that amount will probably astound you.

Multiply the cost per year by 10 (for the next 10 years) and ask yourself what you would rather do with that much money. Do you really want to continue wasting your money with nothing to show for it except possible health problems?

Setting an example

If you have children in your life, you want to set a good example for them. When asked, nearly all smokeless tobacco users say they don't want their children to chew or dip. You can become a good role model for them if you quit now.

Quitting smokeless tobacco

Surveys show that most people who use snuff or chew would like to quit. In one survey, more than half of those who took part said they would try to quit in the next year.

In many ways, quitting smokeless tobacco is a lot like quitting smoking. Both involve tobacco products that contain nicotine, and both involve the physical, mental, and emotional parts of addiction. Many of the ways to handle the mental hurdles of quitting are the same. But there are 2 parts of quitting that are unique for oral tobacco users:

• There is often a stronger need for oral substitutes (having something in the mouth) to take the place of the chew, snuff, or pouch.

• Mouth sores often slowly go away and gum problems caused by the smokeless tobacco may stop getting worse. This is a benefit of quitting that everyone can see.

Help with psychological addiction

Some people are able to quit on their own, without the help of others or the use of medicines. But for many tobacco users, it can be hard to break the social and emotional ties to chewing or dipping while getting over nicotine withdrawal symptoms at the same time. The good thing is, there are many sources of support out there – both formal and informal.

Telephone-based help programs

All 50 states now offer some type of free telephone-based quitting program, which links callers with trained counselors. These specialists help plan a quit method that fits each person's own pattern of tobacco use. With guidance from a counselor, quitters can avoid common mistakes that may make it harder to quit.

Many people find that telephone counseling is easier to use than some other support programs. You don't have to leave home or get child care, and you can do it on nights and weekends. Counselors may suggest a combination of methods including local classes, self-help brochures, medicines, and/or a network of family and friends. One review of studies about smokeless tobacco use found that telephone counseling helped people trying to quit.

Tobacco users can get help finding a program to help them quit tobacco. These are sometimes called tobacco cessation (pronounced sess-a-shun) programs. One such telephone service is the American Cancer Society’s Quitline^® tobacco cessation program, which is available in many states. You can find out more about this and other programs in your area by calling us at 1-800-ACS-2345 (1-800-227-2345).

Support from family, friends, and quit programs

Many former tobacco users say a support network of family and friends was very important during their quit attempt. Other people who may offer support and encouragement are co-workers, your family doctor or dentist, and members of support groups for quitters. You can also check the "National organizations and Web sites" section for information on Nicotine Anonymous. Ask your employer, health insurance company, or local hospital to help you find support groups; or call us.

Don't neglect this vital part of quitting. Surround yourself with other people who don't use tobacco, and tell them about your plans to quit. Warn them that you might not be your usual self for a few days, and ask them to listen and encourage you when you need it. Suggest ways they can help, like going for a walk with you, helping you stay busy, and reminding you that you can do this. If they’ve quit, ask them how they did it and get some tips.

If you have close friends who still use tobacco, ask them not to offer any to you. You're not asking them to quit themselves, but you may not want to spend a lot of time with those who still use tobacco for the first few weeks after you quit. You may find it hard to be with them without being tempted. But if your plan happens to inspire someone to quit with you, you can help and support each other.

What to look for in a tobacco cessation group or class

Tobacco cessation programs are set up to help users recognize and cope with problems that come up during quitting and provide support and encouragement in staying quit. Although many programs focus mainly on smokers, most are open to smokeless tobacco users, too.

Studies have shown that the best programs will include either one-on-one or group counseling. There is a strong link between the intensity of counseling and the success rate. In general, the more intense the program, the greater the chance of success.

Intensity may be increased by having more or longer sessions or by increasing the number of weeks over which the sessions are given. So when considering a program, look for one that has the following:

• at least 20- to 30-minute sessions
• at least 4 to 7 sessions
• at least 2 weeks long

Be sure the leader of the group has training in tobacco cessation. Some communities have a Nicotine Anonymous group that holds regular meetings. This group applies the 12 steps and other principles of Alcoholics Anonymous to tobacco addiction. There is no fee to attend Nicotine Anonymous.

Often your local American Cancer Society or local health department will sponsor quitting classes. Call 1-800-ACS-2345 (1-800-227-2345) for more information.

There are some programs to be cautious about as well. Not all programs are ethical. Be wary of programs that:

• promise instant, easy success with no effort on your part
• use injections or pills with "secret" ingredients
• charge a very high fee – check with the Better Business Bureau if you have doubts
• are not willing to give you references from people who have used the program

A word about success rates

Before you sign up for a tobacco cessation class or program, you may wonder what its success rate is. That's a hard question to answer for many reasons. First, not all programs define "success" in the same way. Does success mean that a person is not using tobacco at the end of the program? After 3 months? 6 months? A year? If a program you're considering claims a certain success rate, ask for more details on how success is defined and what kind of follow-up is done to confirm the rate.

The truth is that programs to help you quit tobacco may give you more of an edge up than trying to quit on your own. But like other programs that treat addictions, they often have a fairly low overall success rate. This does not mean they are not worthwhile, or that you should be discouraged. Your own success in quitting is what really counts, and that is under your control.

What about medicines to help you quit?

Tobacco addiction has emotional, mental, and physical components. Physical addiction can cause you to go through withdrawal symptoms if you try to quit, and for many people this is a hard part of addiction to overcome.

Nicotine replacement therapy

Nicotine replacements (nicotine substitutes) give you nicotine without the other harmful ingredients in tobacco. For cigarette smokers, nicotine replacement therapy (NRT) has been proven to help reduce withdrawal symptoms. Together with counseling or other support, it doubles the chances that a smoker will quit. Fewer studies have been done on how much NRT helps smokeless tobacco users quit. Since both smokers and smokeless users are addicted to nicotine, it makes sense to some smokeless tobacco users to try it.

The Food and Drug Administration (FDA) has approved several NRT products as effective aids for helping people to quit smoking. These include:

• nicotine gum
• nicotine patch
• nicotine lozenges
• nicotine inhaler
• nicotine nasal spray

(For more information on these products, see our document, Guide to Quitting Smoking.)

None of these products has been FDA approved specifically to help people quit smokeless tobacco, as it has not been proven how well they work to help quit smokeless tobacco. The results of some small studies have been mixed, and larger studies are needed. Still, NRT may be useful in helping you quit, or at least in helping reduce your cravings.

Nicotine gum, patches, and lozenges can be bought "over the counter" (without a prescription). Nicotine nasal spray and nasal inhalers are available only with a doctor's prescription.

For smokeless tobacco users, some types of NRT may help more than others. From a behavioral standpoint, nicotine gum and lozenges are oral substitutes that are the most like using smokeless tobacco. They also let you control your dosage to help keep cravings at bay. The nicotine inhaler may not be as useful for smokeless tobacco users, as it is designed to look and feel like a cigarette filter tip. The nicotine patch gives a steady dose of nicotine, but may not help with strong cravings. Still, the patch may be more useful for people who prefer once-a-day convenience. A 2007 study compared higher-dose nicotine patches with the usual NRT doses in heavy users of smokeless tobacco. The researchers found that higher doses were more helpful in reducing withdrawal symptoms.

No matter which type of NRT you choose, make sure to follow the package instructions and don't use any tobacco, including smokeless tobacco, when using nicotine replacement. You may want to talk with your doctor, dentist, or pharmacist before using any of these products.

Getting the most from nicotine replacement

Nicotine replacement therapy only deals with the physical part of withdrawal. These products work best when they are used with other quitting aids such as group sessions or counseling. They may reduce withdrawal symptoms and let you focus on dealing with the mental and emotional aspects of addiction.

If you choose to use it, the most effective time to start NRT is at the beginning of an attempt to quit. Often tobacco users first try to quit on their own, then decide to try NRT. You should not use nicotine replacement if you plan to continue to use any tobacco product. The combined dose of nicotine can be dangerous.

Tobacco users who are pregnant or have heart disease should talk to a doctor before using over-the-counter nicotine replacement.

Prescription medicines

Bupropion

Bupropion (Zyban^®) is a prescription antidepressant in an extended-release form that reduces symptoms of nicotine withdrawal. It is not a form of nicotine replacement. This drug acts on chemicals in the brain that are related to nicotine craving. Bupropion is FDA approved as an aid in quitting smoking, but it is not clear if it is useful for smokeless tobacco users as well. A 2007 study found that it helped reduce cravings and weight gain in people who were trying to quit smokeless tobacco. But in that clinical trial, the group taking bupropion was no more successful at quitting than the group taking placebo (sugar pills). Bupropion works best in smokers if it is started 1 or 2 weeks before the quit date. The usual dosage is one or two 150 mg tablets per day. Talk to a doctor to find out if it might be an option for you.

Bupropion can be used alone or with NRT. You should not take it if you have ever had seizures, serious head injury, bipolar (manic-depressive) illness, anorexia or bulimia (eating disorders), or problems with heavy alcohol use.

Varenicline

Varenicline (Chantix™) is a newer prescription medicine taken as a pill twice a day. It works by interfering with nicotine receptors in the brain. It lessens the physical pleasure from taking in nicotine and helps lessen the symptoms of nicotine withdrawal. Studies have shown it to work as least as well as bupropion (if not more so) in helping people quit smoking, at least in the short term. Its effects against smokeless tobacco have not been studied.

Non-drug products and methods people may use to quit

Some newer tobacco-related and nicotine-containing products have appeared in the past few years. Because they are not marketed to treat nicotine addiction, the FDA doesn’t consider them drugs and doesn’t regulate them. Although some may be helpful, none of these products has been proven to be effective.

Non-tobacco snuff products

These are sold in grocery and convenience stores or by mail order. They are packaged like moist snuff in a tin and come in different flavors. They are made from plants or herbs such as tea, clover, mint leaves, kudzu, or alfalfa. Some have added flavorings and moisteners like glycerin. At least one contains a caffeine-containing herb called guarana, which has quite a bit of caffeine in it.

Non-tobacco snuffs can be used alone or mixed with regular snuff as a person is trying to cut down on tobacco. They are generally considered safe as long as you are not allergic to anything in them, but they have not been reviewed by the FDA. One study that used mint snuff as a substitute found that it helped reduce cravings in smokeless tobacco users who were trying to quit. But those who used the mint snuff were no more likely to quit tobacco than those who didn't. If you choose to try a non-tobacco snuff, check the ingredient list to see what you are getting.

Tobacco lozenges and pouches

Lozenges that contain tobacco (Ariva^®, Stonewall^®) and small pouches of tobacco (Revel^®, Exalt^®) are now being marketed as other ways for smokers to get nicotine in places where smoking is not permitted. They are not sold as ways to quit tobacco. The FDA has also ruled that these are types of smokeless tobacco, not aids to quit smoking or wean off tobacco. This means the FDA does not have authority over them. There is no reason to think these products would have fewer health risks than more common forms of smokeless tobacco.

Nicotine lollipops and lip balms

In the past, some pharmacies made a product called a nicotine lollipop. These lollipops often contained a product called nicotine salicylate with a sugar sweetener. Nicotine salicylate is not approved for pharmacy use by the FDA. The FDA has warned pharmacies to stop selling nicotine lollipops and lip balm, calling the products "illegal." The FDA also said "the candy-like products present a risk of accidental use by children."

Other smoking cessation products like these may not use nicotine salicylate, and may be legal. But all of them still pose a risk for children and pets if they are not stored safely and disposed of where children and pets cannot get them.

Nicotine water and nicotine wafers

Like lozenges and pouches, these products have been sold in recent years as ways to get nicotine in places where smoking is not allowed. They are not marketed as aids to quitting smoking, but questions about their safety and legality have been raised.

Other non-drug quitting aids

Hypnosis

Hypnosis methods vary a great deal, which makes hypnosis hard to study as a way to quit tobacco. For the most part, reviews that looked at studies of hypnosis to help people quit smoking have not supported it as a quitting method that works. As a way to quit using smokeless tobacco, hypnosis has been studied even less. Still, it might be useful for some people. If you are interested in trying it, ask your doctor if he or she can recommend a good hypnotherapist.

Acupuncture

This method has also been used for quitting tobacco, but there is little evidence to show that it works. It involves putting small needles into the skin, usually around the ears. (For more information on acupuncture, see our document, Acupuncture.) For a list of local physician acupuncturists, visit the American Academy of Medical Acupuncture online at www.medicalacupuncture.org, or call 310-364-0193. Low-level laser therapy is a related technique, which also has very little evidence to support its effectiveness (see our document, Cold Laser Therapy).

Tobacco deterrents

These include over-the-counter products that change the taste of tobacco, "quitting diets" that are supposed to curb nicotine cravings, and combinations of vitamins. There is little scientific evidence to support claims that these methods work.

Homeopathic aids and herbal supplements

Because they are sold as dietary supplements (rather than drugs), these products don't need FDA approval. The manufacturers don't have to prove they're effective, or even safe. Be sure to look closely at the label of any product claiming it can help you quit tobacco. Dietary supplements and homeopathic remedies have no proven track record of helping people quit tobacco (see our document, Homeopathy).

How to quit

Tobacco users often say, "Don't tell me why to quit, tell me how." There is no one right way to quit, but there are some key elements in quitting for good. These 4 factors are most important:

• making the decision to quit
• setting a quit date and choosing a quit plan
• dealing with withdrawal
• staying quit (maintenance)

Deciding to quit

The decision to quit tobacco use is one that only you can make. Others may want you to quit, but to get through the first few weeks without tobacco, the real commitment must come from you. If you try to quit for someone else, you may find yourself blaming or resenting them later.

Researchers have looked into how and why people stop using tobacco. They have some ideas, or models, of how this happens.

The Health Belief Model says that you will be more likely to stop using tobacco if you:

• believe that you could get a tobacco-related disease and this worries you
• believe that you can make an honest attempt at quitting
• believe that the benefits of quitting outweigh the benefits of continuing to use tobacco
• know of someone who has had health problems as a result of their tobacco use

How can I know if I'm ready to quit?

The Stages of Change Model identifies the stages that you go through when you change a behavior. Here are the stages as they apply to quitting tobacco use:

• Pre-contemplation: At this stage, the tobacco user is not seriously thinking about quitting right now.

• Contemplation: The tobacco user is actively thinking about quitting but is not quite ready to make a serious attempt yet. This person may say, "Yes, I'm ready to quit, but the stress at work is too much," or "I don't want to gain weight," or "I'm not sure if I can do it."

• Preparation: Tobacco users in the preparation stage seriously intend to quit in the next month and often have tried to quit in the past 12 months. They usually have a plan.

• Action: This is the first 6 months when the user is actively quitting.

• Maintenance: This is the period of 6 months to 5 years after quitting when the ex-user is aware of the danger of relapse (going back to the old habits) and takes steps to avoid it.

Where do you fit in this model? If you are thinking about quitting, setting a date and deciding on a plan will move you into the preparation stage. That's the best place to start.

List your reasons for quitting

Tobacco users have many reasons for wanting to quit. We listed some of them before. But what motivates you to quit may not be the same as what motivates others. Think about making a list of the reasons you want to quit – one you can refer to later if you’re feeling tempted. The list might include some or all of the following, but be sure to add your own reasons:

• I want to be healthier.
• I already have problems with my gums/teeth, and I don’t want them to get worse.
• I don’t want to spend my money on this.
• I can’t chew/dip at work/school.
• I want to be able to go to a movie/mall/ballgame without worrying about it.
• I want to prove I can do it.
• I don’t want it to control me.
• The people I care about don’t like it, and want me to quit.
• I want to set a good example for the kids.

Setting a quit date and deciding on a plan

Once you've made a decision to quit, you're ready to pick a quit date. This is a very important step. Pick a day in the next month as your "Quit Day." Picking a date too far in the future gives you time to rationalize and change your mind. But give yourself enough time to prepare and come up with a plan.

You might choose a date that has a special meaning, like a birthday or anniversary, or the date of the Great American Smokeout (the third Thursday in November each year). Or you may want to simply pick a random date. Circle the date on your calendar. Make a strong, personal commitment to quit on that day. There is no one right way to quit. Some tobacco users prefer to quit "cold turkey" – that is, they stop completely, all at once. They use tobacco until their Quit Day and then stop. Others may cut down on tobacco for a week or 2 before their Quit Day. There is more than one way to do this.

Cutting down on how much you use: One way to do this is to cut down on the number of times or the amount you dip or chew each day. By doing this, you slowly reduce the amount of nicotine in your body. Try cutting back to half of your usual amount before you quit. If you usually carry your tin or pouch with you, try leaving it behind. Carry something else to put in your mouth instead.

Cutting back on when and where you use: You can also try cutting back on when and where you dip or chew. This gives you a chance to notice when your cravings are the worst. It helps you decide on a game plan if you know what triggers your cravings. Again, once you've decided not to use tobacco at a certain place, leave your pouch or tin at home when you go there. Try your substitutes instead (See the section "Some steps to help you prepare for your Quit Day").

Putting off using tobacco when you have a craving: Go as long as you can without giving into a craving. Start by trying for at least 10 minutes, then longer and longer as you near your Quit Day. Pick your 3 worst triggers and stop dipping or chewing at those times. This will be hard at first, but practice will make it easier.

Quitting tobacco is a lot like losing weight. It takes a strong commitment over a long period of time. Users may wish there were a magic bullet – a pill or method that would make quitting painless and easy. But there is nothing like that. Nicotine substitutes can help withdrawal symptoms, but they work best when used as part of a quitting plan that addresses the physical, mental, and emotional parts of quitting.

Some steps to help you prepare for your Quit Day

• Pick the date and mark it on your calendar.

• Tell friends, family, and co-workers about your Quit Day, and let them know how they can help.

• Stock up on other things to put in your mouth – sunflower seeds, sugarless gum, carrot sticks, beef jerky, cinnamon sticks, and/or sugarless hard candy.

• Decide on a plan. Will you use nicotine replacement therapy? Will you go to a class or program? If so, sign up now. Find out where and when they meet, so that you are ready.

• Consider seeing your doctor or dentist. Have them check your mouth, and discuss your plan for quitting with them.

• Set up a support system. This could be a group class, Nicotine Anonymous, or friends or family members who have quit and are willing to help you.

• Make a list of your "triggers" – situations, places, or feelings that make you more likely to chew or dip. Being aware of these can help you avoid them or at least be ready for them.

• Think back to your past attempts to quit. Try to figure out what worked and what did not work for you.

Quitting and staying quit is a matter of planning and commitment, not luck. Decide now on your own plan. Some options include joining a tobacco cessation class, calling a cessation support line, going to Nicotine Anonymous meetings, using nicotine replacement, online support, and using self-help materials such as books and pamphlets. For the best chance of success, your plan should include 2 or more of these options.

On your Quit Day, follow these suggestions:

• Don't use tobacco of any kind. This means none, not even a pinch!
• Get rid of all snuff or chew and related products.
• Keep active – try walking, exercising, or doing other activities or hobbies.
• Keep substitutes handy to put in your mouth.
• Drink lots of water and juices.
• Begin using nicotine replacement if that is your choice.
• Call a cessation support line, attend a tobacco cessation class, or start following your self-help plan.
• Avoid situations where the urge to dip or chew is strong.
• Avoid alcohol. It can weaken your resolve to quit
• Think about changing your routine. Sit in a different chair at home, drive a new way to work, or choose foods and drinks that make tobacco taste bad.

Dealing with withdrawal

Withdrawal from nicotine has 2 parts:

• physical withdrawal
• psychological or mental withdrawal

The physical withdrawal symptoms, while annoying, are not life threatening. If you choose to use nicotine replacement, it can help reduce many of these physical symptoms. But most users find that the bigger challenge is the mental and emotional part of quitting.

If you have been using tobacco for any length of time, it probably has become linked with many of your activities – watching TV; going to sporting events; fishing, camping, or hunting; or driving your car. It will take time to "un-link" tobacco use from these activities. That's why, even if you are using the patch or gum, you may still have strong urges to use tobacco.

One way to deal with these urges or cravings is to recognize rationalizations as they come up. A rationalization is a mistaken belief that seems to make sense to you at the time but the thought is not based on reality. If you have tried to quit before, you’ll probably recognize some of these common rationalizations:

• I’ll just use it to get through this rough spot.
• Today is not a good day; I’ll quit tomorrow.
• It's my only vice.
• How bad is tobacco, really? Uncle Harry chewed all his life and he lived to be over 90.
• You've got to die of something.
• Life is no fun without chewing (or dipping).

You probably can add more to the list. As you go through the first few days without tobacco, write down any rationalizations as they come up and recognize them for what they are: messages that can trick you into going back to using tobacco. Look out for them, because they always show up when you're trying to quit. After you write down the idea, let it go from your mind. Be ready with a distraction, a plan of action, and other ways to re-direct your thoughts to something else. Use the ideas below to help keep your commitment to quitting.

Avoid temptation. Stay away from people and places where you are tempted to use tobacco. Later on you will be able to handle these with more confidence.

Change your habits. For example, switch to juices or water instead of alcohol or coffee. Take a different route to work; take a brisk walk instead of a chew. Here are some more ideas:

Alternatives. Use oral substitutes such as sunflower seeds, beef jerky, sugarless gum or hard candy, or raw vegetables such as carrot sticks. Take a sip or a bite of something that makes tobacco taste bad. Try the mint (non-tobacco) snuff or another herbal version you've chosen if you need help with cravings.

Activities. Exercise or do hobbies that keep your hands busy (such as woodworking, puzzles, gardening) and require enough brain focus to distract you from the urge to use.

Deep breathing. When the urge to use strikes, relax, breathe deeply, and picture your lungs filling with fresh, clean air. Remind yourself of why you are quitting and the benefits you'll gain.

Delay. If you feel that you are on the verge of giving in, delay. Tell yourself you must wait at least 10 minutes. Often this simple trick will allow you to move beyond the immediate urge to use tobacco.

Reward yourself. What you're doing is not easy and you deserve a reward. Put the money you would have spent on tobacco in a jar every day and then buy yourself a weekly treat. Buy a magazine or some new music, go out to eat, call a friend long-distance. Or save the money for a major purchase. You can also reward yourself in ways that don't cost money: take time out to read, work on a hobby, or take a relaxing bath.

Enjoy the new you. Make an appointment with your dentist to get your teeth cleaned and whitened. Take your spouse or partner out on a date, even if you've been married for years. If you're not in a relationship, start talking to someone you'd like to know better. You won't have to worry about your tobacco-breath or brown teeth!

Staying quit (maintenance)

Staying quit is the final, and most important, stage of the process. You can use the same methods to stay quit as you did to help you through withdrawal. Plan ahead for those times when you may be tempted to use tobacco. Think about alternatives and activities you can use to cope with these situations.

More dangerous, perhaps, are the unexpected strong desires to use tobacco that crop up months or even years after you've quit. To get through these without relapse, try the following:

• Review your reasons for quitting – look at your list and think of all the benefits to your health, your finances, and your family.

• Remind yourself that there is no such thing as just one chew or dip.

• Ride out the desire. It will go away, but do not fool yourself into thinking you can have just one dip or chew.

What if you do use tobacco after your Quit Day?

The difference between a slip and a relapse is within your control. A slip is a one-time mistake that is quickly corrected. A relapse is going back to your former habit. You can use the slip as an excuse to go back to using tobacco, or you can look at what went wrong and renew your commitment to staying off tobacco for good.

Even if you do relapse, try not to get too discouraged. Many people are not able to quit for good on the first attempt. In fact, it takes most people many attempts before quitting for good. What’s important is figuring out what helped you in your attempt to quit and what worked against you. You can then use this information to make a stronger attempt at quitting the next time. Learn from your mistakes – don't give up!

Weight gain

Although it is well known that smokers often gain weight when they quit, fewer studies have been done on quitting smokeless tobacco. Researchers in a small 2007 study looked at people who were trying to quit smokeless tobacco. They gave bupropion to one group, and sugar pills (placebo) to the other. Even though there was no significant difference in quit rates between the groups in the study, there was a difference in weight gain among the people who quit successfully. The researchers found that quitters who took the drug gained an average of about 4 pounds, while those in the control group gained about 7 pounds. These findings suggest that people who quit smokeless tobacco have some risk of weight gain.

You are more likely to succeed in quitting if you deal with quitting tobacco first, and then later take steps to reduce your weight. While you are quitting, try to focus on ways to help you stay healthy, rather than on your weight. Stressing about your weight may make it harder to quit. Eat plenty of fruits and vegetables and limit the fat. Be sure to drink lots of water, and get enough sleep and regular physical activity.

Walking is a great way to be physically active and increase your chances of staying quit. Walking can help you by:

• reducing stress
• burning calories and toning muscles
• giving you something to do instead of thinking about tobacco

No special equipment or clothing is needed for walking, other than a pair of comfortable shoes. And you can do it pretty much anytime or anywhere. Try the following:

• Walk around a shopping mall.
• Get off the bus one stop before you usually do.
• Find a buddy to walk with during lunch time at work.
• Take the stairs instead of the elevator.
• Walk with a friend, family member, or neighbor after dinner.
• Push your baby in a stroller, walk your dog, or offer to walk someone else's dog.

Set a goal of 30 minutes of physical activity 5 or more times a week. If you don't already exercise regularly, please check with your doctor before starting an exercise program.

Dealing with stress

Tobacco users often mention stress as one of the reasons for going back to using tobacco. Stress is a part of everyone's life. The difference is that tobacco users have come to use nicotine to help cope with stress and unpleasant emotions. When quitting, you have to learn new ways to handle them. This can be tough, especially during the first few days. It’s important to let those around you know what you’re going through and to ask them for their understanding. Nicotine replacement can help to some extent, but for long-term success other strategies are needed.

As mentioned before, physical activity is a good stress reducer. It can also help with the short-term sense of depression that some tobacco users have when they quit.

Stress-management classes and self-help books may also be helpful. Check your community newspaper, library, or bookstore.

Spiritual practices such as admitting that you can't control your addiction and believing that a higher power can give you strength have been used with much success to deal with other addictions.These practices, along with the fellowship of others on a similar path, are a key part of 12-step recovery programs. These same principles can be applied to quitting tobacco. Nicotine Anonymous uses these 12 steps (see "National organizations and Web sites" section). You may also want to use other spiritual practices like prayer and meditation, especially if they have helped you through tough times in the past.

Where can I go for help?

It’s hard to give up tobacco. But if you are a tobacco user you can quit! Many organizations offer information, counseling, and other services focusing on how to quit and where to go for help. Other good resources to ask for help can include your doctor, dentist, local hospital, or employer. You can call us at 1-800-ACS-2345 (1-800-227-2345) or visit us online at www.cancer.org. There are also other groups listed below that can help you.

Additional resources

More information from your American Cancer Society

We have selected some related information that may also be helpful for you. These materials may be viewed on our Web site or ordered from our toll-free number.

• Child and Teen Tobacco Use

• Questions about Smoking, Tobacco, and Health (also available in Spanish)

• Tobacco-Related Cancers Fact Sheet

National organizations and Web sites*

If you want to quit smoking and need help, contact one of the following organizations. In addition to the American Cancer Society, other sources of patient information and support include:

Centers for Disease Control and Prevention
Office on Smoking and Health
Toll-free number: 1-800-CDC-INFO (1-800-232-4636)
Web site: www.cdc.gov/tobacco/quit_smoking/index.htm

Kill the Can
(online support for those committed to quitting smokeless tobacco)
Web site: www.killthecan.org

National Cancer Institute
Toll-free number: 1-800-4-CANCER (1-800-422-6237)
Web site: www.cancer.gov

Nicotine Anonymous
Toll-free number: 1-877-879-6422
Web site: www.nicotine-anonymous.org

Smokefree.gov
(Online materials, including info on state telephone-based programs)
Toll-free number:1-800-QUITNOW (1-800-784-8669)
Web site: www.smokefree.gov

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-ACS-2345 (1-800-227-2345) or visit www.cancer.org.

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Last Medical Review: 11/03/2008
Last Revised: 05/22/2009