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Tobacco Cessation and Nicorette Gum: 
As Applied to College Students
A Pilot Study

Jacob "Alaska" Oruoja

Professor Joesph Troisi
Professor Paul Finn

 

Welcome    

Thanks for visiting my website.  My thesis was based on what interested me, chewing tobacco and behavior.  I hope ou enjoed it and feel free to email me with any feedback you may have.-Jake

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Introduction       

Chewing Tobacco Use and Side Effects

    Smokeless Tobacco use is at an all time high and is one of the few drugs on the steady increase of use. (Darmody, 1994; Schaffer 1986; Disco, 2001)  Although the risks of tobacco are known by many, having the knowledge of the effects has not curbed the incredible increase in use.  Most of the efforts to curb tobacco use are focused on smokers and little has been done for chewing tobacco users. (Coffey and Lombardo, 1998; Severson 2000).
    Some key terms are needed to understand the study at hand.  Chewing Tobacco is defined as smokeless tobacco that is placed into the mouth for delivery of nicotine.  Chewing Tobacco is frequently over generalized with the term smokeless tobacco. Chewing tobacco is commonly
confused with snuff, smokeless tobacco that is inhaled as its source of delivery.  When placed into the mouth, chewing tobacco users frequently refer to the chewing tobacco as taking a pinch, dip, or a lipper.  
     Many users of chewing tobacco report that they have tried to quit the habit, but report severe difficulty in abstaining from dip. Factors that can play a role in quitting include; perceived reaction of onlookers and friends, seen negative side effects (browning of the teeth and receded gum line), and the cost of the habit.  While there has been abundant research on smoking cessation with the use of the nicotine replacement therapy (i.e., transdermal patch or Nicorette gum), little research however has addressed nicotine replacement therapy for individuals who use chewing tobacco.  Participants in chewing tobacco cessation studies should be regular users of dip who report the  “want to quit” (E. Kehoe and N. White, 2002), for it has been shown that those that do not want to quit will not
    Cessation programs are needed to help diminish the use of smokeless tobacco use.  Previous attempts have been made to study cessation programs.  For example, Haksukami (2000) examined the use of the patch on cessation programs, however Haksukami found minimal results and discusses the need for further research.  Sinusas (1993) focused a cessation program on the use of Nicorette gum in baseball players.  The results found that after 6 months 3 of 14 users had quit, and after one year only one had completely abstained from use.  The players in the study did say, “quitting the habit (chewing tobacco) is difficult.
     Chewing tobacco users have been found to have four times the risk of oropharyngeal cancer than non-tobacco users and have an increased rate of developing cancer in the larynx, esophagus, stomach, and bladder.  Those who chew tobacco for even a short time are more susceptible to periodontal disease, abrasion and staining of teeth, leukoplakia and even cardiovascular disease (Disco, Marilyn; Moorman, Robin; Noble, Sarah 2001; Stevens 1995).   

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Smokeless tobacco use: Context and Cues
  
     Smokeless tobacco use is influenced greatly due to an individual’s social context (Altman and Jackson, 1998).  Many users develop their habit due to their parent’s risk taking behaviors with nicotine.  Socialization occurs when a parent smokes or dips and then their children have seen and incorporated this behavior into their own context.  Then when tobacco users see their peers engaged in tobacco use, they develop it as their own and start use.  
    A recent study devised by Spielberger (2000) looked at what caused smokeless tobacco users to start use and what made them continue use of smokeless tobacco.  Original use of smokeless tobacco was initiated from (in order from 1 to 10); see if I would enjoy it, try something new, friends enjoy it, many people do it, to feel relaxed socially, did not want to refuse friends, parents enjoy it, advertisements, wanted to show their independence, older siblings enjoy it.  Continuation of use resulted from (in order from 1 to 10); enjoyment, relaxation, something to do, stimulating, boredom when not using it, helps to forget worries, facilitates thinking, feel comfortable amongst friends, friends use it, advertisements are attractive.  Spielberger (2000) also found that individuals that use smokeless tobacco are extremely extroverted and more likely to be aggressive and impulsive.
    The findings of Spielberger reinforce the idea that individuals that use chewing tobacco are influenced socially.  The main reason for one to start using was to fit in socially and to follow suit of their peers.  Continuation of use was found to be caused by relaxation in stressful situations and peer acceptance.  
    Stress is a cue for chewing tobacco according to Spielberger, and this reinforces the idea that users of smokeless tobacco are impulsive and aggressive.  Users that fit this scheme, impulsion and aggression, can be seen as legitimate in using chew as a stress relief after they experienced high levels of stress from their aggressive nature and then using the calming nature of nicotine and chew under this form of stress, forming a conditioned release for their stress.
    Coffey and Lombardo (1998) found that under varying stress tasks, tobacco users look to tobacco as their preferred form of relief over fifty percent of the time. Further more it was discovered that sensory cues associated with tobacco use become conditioned hence causing further use.  The combined research of Coffey and Lomardo with that of Spielberger informs one that stress was calmed by tobacco and now has become a condition for tobacco use.  In conclusion a new stimuli must be paired with stress to eventually eliminate the need for tobacco during stress.    
    It has been ignored in previous studies the pairing of friends and family with smokeless tobacco use.  The cues involved in eliciting a dip is then not only stress but social interaction.  Not only does one have to address peer activity and the generalization of activity associated with peer use, but establishment of cues is needed to address all the associations behind use of chewing tobacco.

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Nicotine Examination with Animal Research  
   
    Research in humans and drugs is limited by ethical reasons, especially the fear of potential harm to participants.  It is because of the dilemma of participant harm that some research with human participants is somewhat limited.  Limitations on research have leaded some researchers to investigate nicotine within the context of animals.
    Nicotine use develops strongly within the paradigm of classical conditioning.  Unconditioned
stimuli become very important in the use of nicotine, especially in the context of performance
anxiety.  When an individual pairs nicotine with performance in sports, they then have a new unconditioned stimulus, nicotine, pair with the condition response, performance.  Kehoe and White (2002) have examined classical conditioning and pairing of new stimuli to help eliminate the drive for nicotine in rats.
    Reductions of nicotine in rats have shown a greater yielding of extinction than completely eliminating nicotine in rats.  Reduction showed less withdrawal and reacquisition to nicotine, than those trying to go cold turkey.   Subsequent experimentation showed spontaneous recovery from nicotine was more likely to occur after reduction in stimuli.  When effect on motor ability and non specific performance was examined, rats being slowly weaned from the unconditioned stimuli, nicotine, showed little or no performance depravation compared to those rats completely withdrawn from the US. Sensitivity to the lack of US was very prominent within the rats that were significantly or completely withdrawn from nicotine.  In order to extinguish the use of nicotine and withdrawal, research associated with abstaining from nicotine has shown that a slow removal of stimuli received the greatest extinction possibility.
    Individuals have a tendency to exhibit greater use of nicotine within their original context of use.  Athletes show a greater craving for nicotine when placed within their field of play, (Darmoody, 1994).  Clark and Fibiger (1987) used rats to determine the effect of conditioned place preference in rats.  Examination of nicotine within place preference was examined within a control group and independent grouping of rats.  The rats were determined to have no place preference, however nicotine did have a behavioral presence within the place of conditioning.  
     When combined with the research of Kehoe and White (2002) it can be assessed that the rats had fiend for nicotine.  The nicotine had produced a shift of preference by reducing neophobia associated the non-preferred side, Clarke and Fieber 1987.  Rather than showing a positive reinforcement for the place of use, the rats showed a positive reinforcement to go the place of the drugs specified place of use.  A direct connection was not shown in the rats as to where they used the drug, it was shown that they preferred the ability to receive the drug in the prearranged place.
It is concurred that the rats examined showed a preference for the drug given as a stimuli and needed to be weaned from the nicotine.  Within context it was shown that the drug became a US and reinforced use within that certain context, Kehoe and White (2002) however it may not be the place where the drug is given as a factor, but rather the place it is taken is assumed to become a positive reinforcer directly, and becomes a deterrent compared to the negative reinforcement of drug withdrawal and preference away the original site of use.

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Addictive Behavior                  

    Addiction is defined as a compulsive need for and use of a habit forming substance characterized by tolerance and by well-defined psychological symptoms upon withdrawal, Merriam-Webster 1998.  Chewing tobacco is an addictive substance as stated by the warning label on the containers, also known as tins.  Formerly on tins of various brands of chewing tobacco were forced by the surgeon general to state, this product maybe addictive and may cause gum disease and tooth loss.
Shaffer (1986) stated that nicotine is seen as a psychoactive drug that has the capacity to cause a chemical dependency.  Nicotine’s addictive nature is refined within Shaffer’s belief that smokeless tobacco is best considered as a behavioral pattern of compulsive use characterized by overwhelming involvement.  Chewing tobacco develops into a habit forming substance in that certain activities lose their appeal or will be avoided without use.  Some users of chewing tobacco have developed a habit of playing video games with a pinch in their mouth.  Without chewing tobacco some users will not play video games without a pinch in their mouth.  Users have now developed a behavioral pattern of use.
     Understanding under what conditions use of chewing tobacco is defined, is essential in understanding a user’s addiction.  Under what conditions and normal place of use defines a user’s behavior, hence signifying the addiction.  In order to address the problem of addiction the use and context is needed in order to assess how to best address the problem.
     A systematic study has examined signs and symptoms that occur during depravation from chewing tobacco addicts (Hatsukami, 1986).  Results in Hatsukami’s study have shown that withdrawal symptoms in chewing tobacco users are most consistently associated with various measures of users’ intake.  Addiction in chewing tobacco users is also committed to the number of dips a day and duration of such dips.
     Hatsukami neglects to note that under certain contexts users will dip.  Drawing from Schaffer and Hatsukami, one must assess under what circumstances a user will dip under.  This displays their conditions of addiction and will provide under what circumstances a user dips and how often.  If a chewing tobacco user associates dipping with playing videos that will be their context.  How often they play and use dip is then their specific nature and will define their amount of use and number of dips. 
     Fagerstrom (1999) relates the ideal of needing to know context in his questionnaires that are based upon number of dips a day, size, and under what contexts with smokers.  This ideal needs to be applied to chewing tobacco users to initially conclude what circumstances cause chewing tobacco’s use and what sustains their use.  A survey of such magnitude would allow researchers seeking to evaluate addiction to note within what contexts and how to address the problem later in cessation studies.
     A later study of Hatasukmi and Severson (1999) gave light to notarizing the effectiveness of use and sustaining behaviors.  Users of smokeless tobacco increase their use over time for the positive effects received from use.  Those positive effects are stimulation, relaxation, mood modulation, and improvement of cognitive functioning.  These positive effects help sustain use of chewing tobacco.
Several studies of college athletes have shown reinforcing factors from perceived cognitive enhancement and the relaxing effect on nerves and stimulation of the body, while calming overall attitude.  These reinforcing ideals can be later placed under circumstances of stress, a video game player unable to beat a level, or stimulate reaction of perception, as a baseball player watching a dropping ball and being able to assess where it will drop faster.

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Reinforcement and Behavioral Cues
  
     Reinforcement and behavioral cues play an essential part in maintaining use of chewing tobacco.  Reinforcers are that which establishes continuation of use through positive reaction.  Behavioral cues are situations in which behavior is condoned and appreciated within.  Through reinforcement and behavioral cues chewing tobacco use is maintained.
    One form of reinforcement is a perceived performance enhancement, Keenan 1998.  Through perceived enhancement an individual will continue use of chewing tobacco in order to reach their perceived peak performance.
    A second form of reinforcement is the physical reaction from the nicotine.  Nicotine causes the user to become relaxed and feel like they “fit” into a social setting.  Chewing tobacco users also feel more stimulated, through increased heart rate, and seem to do better in motor skill activities.
    A third form of reinforcement is peer review.  Although generally associated as a behavioral cue, positive peer review is a reinforcer in causing an individual to see himself/herself better.  The pressure of trying to fit in is difficult on an adolescent (Hatasukami, 1999), and being able to fit in suits an individual and makes them feel more at ease, making it a positive reinforcement.
    Behavioral cues are especially expressed through the media.  Through examples of professional athletes and Outdoorsman, chewing tobacco can make an individual feel “more masculine” (Hatasukami, 1999)
     Modeling of peers and family is another key factor that reinforces a chewing tobacco users use of chewing tobacco.  Younger children are prone to mimicking parents use of tobacco and adolescents are more prone to peer mimicking.  Regardless of age and length of use, all chewing tobacco users are acceptable to following their friends in use of chewing tobacco. 

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Smokeless Tobacco Cessation on Performance  

    It has been said that using chewing tobacco can improve performance, especially in the context of athletics.  Is chewing tobacco truly a performance enhancer or is it a perceived myth, recent research has searched for the answer. 
     Nicotine has been shown to be a stimulant with relaxing qualities, to reduce tension, and a key factor in cognitive/behavioral aspect within the athlete’s perceived ability.  Studies by Keenan (1998) and Gottlieb (1992) examined varying factors and have determined chewing tobacco to not enhance performance of college athletes, but rather give a perceived enhancement of ability.
Gottlieb (1992) found that those using chewing tobacco rated their performance higher than their actual outcome in 388 college athletes, varsity and intramural football and baseball players, from those rating their performance without chewing tobacco.  Gottlieb concluded two key factors in causing a higher self rating in chewing tobacco user’s to be a strong team belief in a “performance edge” from chewing tobacco and the ritual of chewing tobacco use.
     Gottlieb’s study (1992) results in noting significance in self-report of performance can be placed back to the effects of chewing tobacco.  Nicotine has a calming effect and stimulates the heart.  The internal process of feeling calmer and more on “edge” is the reason that athletes may seem to have a competitive edge, although it is only perceived.
    Keenan (1989) had similar findings as Gottlieb, as in chewing tobacco users have no advantage in reaction time over non users, even though users believed they had an advantage when dipping then when not dipping.  Keenan concluded one cause of the perceived enhancement to be the media’s promotion with use of star athletes in advertising.  Keenan examined withdrawal and state dependent learning as another factor of chewing tobacco users perceived enhancement in performance.
    Many athletes that use chewing tobacco have a perceived performance enhancement.  Research has shown that the performance enhancement has been clearly aroused through misconceptions of nicotine’s effects and rituals.  Although no enhancement of performance is seen, mentally athletes still believe in some enhancement through use.  What may attribute further contribution to this ideal maybe the use through behavior and cognitive effect. 

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Smokeless Tobacco Cessation Programs   

    Many cessation programs have been implemented in order to help chewing tobacco users quit their use.  Programs have been varied from explaining the problematic nature of chewing tobacco at dentists’ offices to a complete cessation program at an athletic team level. All programs have had aspects that have enabled them to help some users quit but have had aspects make them fail.  It is important to examine these programs and note their successes and failures.
    Stevens (1995) examined the effectiveness of chewing tobacco cessation at a dental office.  Two groups were established, one being a regular dental examination and self quitting, while the second group was paid special attention to areas of the mouth that dip is used and explained damages and possible complications of chewing tobacco by a dental hygienist.  The second group was followed up with a self-help video and manual.
    Results from Stevens found that a six percent increase in tobacco cessation after one year in group two over group one.  Strongpoints in-group two was a thorough explanation of chewing tobacco from a doctor, self help manual, and follow up phone calls after week one, month 3, and 1 year.  Weak points to the study were no inclusion of family and friends in the intervention and no alternatives to oral fixation were offered.
    Overall dental assistance is helpful in chewing tobacco cessation, but chewing tobacco has an addictive factor and the patient will not always see the oral complications of use (Glass, 1994).  A patient must feel the drive to quit and an established chewing tobacco cessation program that is better suited to deal with addiction.
    Severson (2000) examined chewing tobacco cessation through self-help methodology.  Three groups were randomly assigned to one of three groups.  One group received a 1-800 phone number to call in times of need, one group received a self-help manual, and the last group received a self-help manual accompanied by a video and two phone calls.
    According to Severson some key points were that the study was cheap and easily conducted. 
Success ranged from the 1-800 number 16 percent cessation to 28 percent cessation of the self-help manual and phone calls.  Severson noted a key factor in phone councilors being able to address behavioral issues.  Assessment of no dips compared to minimization and serious attempts to quit were also analyzed.
    Problems with the study were varied.  In the 1-800 number participants were to call and left open to be swayed by friends, family, and peers.  The self-help manual did not give follow up and was left for the individual interpretation and did not have to actually read the manual.  
    The problems faced in the manual and calls study were at a minimum.  They addressed behavioral issues and mentioned avoiding risky behaviors.  Unlike groups one and two, the phone calls were more personal to the individuals and had contact with someone addressing them, the other groups seemed to be addressed less personally and may have effected calling times in the 1-800 study.
    The manual explained complications and ways to quit chewing tobacco.  This is a good idea if the participants read the whole manual, of which less that seventy percent did.  Public health issues of chewing tobacco were addressed more adamantly than those issues particularly dealing with the individual.
      In looking at creating a cessation program one should look at relevant sources into the very group they are examining.  Two specific published studies have looked at chewing tobacco cessation at the collegiate athlete level, (Darmody, 1984 and Walsh, 1999).  Darmody (1984) examined use through team intervention via NCAA regulated enforcement.  Walsh, 1999, looked at various schools and did either a team intervention or control groups.
    Darmody (1984) did an assessment of forty three users of chewing tobacco.  A two part intervention was implemented; part one consisted of education of negative effects of chewing tobacco and an oral screening, part two consisted of enforcement of NCAA policy on non-use of chewing tobacco at practice or games.  Finally counseling was available to participants.
    Darmody (1984) focused on the context in which many users used chewing tobacco.  Coaches and assistants were required to enforce a strict no use policy of chewing tobacco in their presence on the field.  Stopping use at practice is a direct attack at behavior and peer review.  The problem is that use outside of practice and drive to quit was not addressed.  Consequences were made for those using chewing tobacco as regarded by NCAA rules to substance abuse on the field.
    Darmody’s study in 1984 was well rounded and attacked the key points of behavior and peer review through consequences.  A problem is the fact that users were forced to quit.  Drive to quit was not addressed and other factors of use, addiction and friends, was not addressed within the study.
    Walsh (1999) examined chewing tobacco in several hundred college athletes.  Two groups were established for the study, one being a team intervention and group two being a control group.  A complete and thorough study was done in examining varying aspects within the team nature.
    The first aspect examined was group conformity.  The team was taken together and explained the complications from chewing tobacco by a dentist and then talked to individually.  Cognitive social learning was another issue addressed.  Addressing the team and those chewing tobacco was and is associated with, was instrumental.
    Individuals were then asked to establish what triggers them to chew and how to prevent these situations.  Participants were also asked to set a quit date and stick to it by slowly reducing use and going cold turkey as the date comes. Those afraid of withdrawal and craving were given the option of 2mg Nicorette gum to ease these problems.  Two calls were made to each participant by a doctor to address concerns and verify adjustment away from risky behaviors.
    Walsh’s study in 1999 seemed to be fairly complete.  Only issues unforeseen were family and friends that chew outside of the program.  Peer pressure from roommates and neighbors were other potential factors that could decrease success rate.  The phone calls from the doctor and use of self-report seemed to keep the study in effect and help prevent use.  The control group had a success rate less than five percent, the success rate doubled with use of the team intervention program.
    Many studies have looked at helping chewers quit their habit.  Key factors in successful programs have been; self-report, team intervention, doctor assessment of problems and risks, follow up calls by trained professionals, and assessment of risks and possible ways of avoidant behaviors.
    No cessation program has had a succession rate of over thirty percent and the mass majority stands around ten percent when a large enough population is available to assess.  The inability of many to quit use for over a year is astounding, and gives light to the need of more cessation programs and a look at programs with potential success rates to help reduce use.

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Nicorette Gum and Chewing Tobacco

    Nicorette Gum is traditionally associated with helping smokers quit use of cigarettes.  Nicorette Gum is used to reduce withdrawal symptoms and craving of nicotine. (Physicians Desk Reference). Few studies have been done to examine the use of Nicorette on chewing tobacco cessation programs. 
    Walsh’s study in 1999 offered users Nicorette in order to help participants deal with withdrawal.  Sinusas (1993) examined gum as an over cessation program in its own.  The study examined the ability of 88 users of chewing tobacco to quit with the assistance of the gum.  It was a preliminary study and its results were inconclusive.  Sinusas (1993) did note his studies lack of behavioral control.  The key point made within the study focused upon users of the gum suggesting it had a positive value to quitting and they would recommend Nicorette gum to others, despite their own complaints of negative side effects.

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Hypothesis                                  
   
    Chewing tobacco use is on the rise in America.  There are many negative side effects of chewing tobacco including higher rates of cancer and oral problems.  It is pertinent that researchers examine ways of assisting chewing tobacco users to quit.
    One focus needed in order to help chewing tobacco users quit is examining social context and what conditions make them dip and sustain their behavior.  Some cues have tended to lead to family, friends, and peers and activities related to other users.  Media, social context, such as playing on a team, and masculinization of chewing tobacco in the media help maintain the use of chewing tobacco.  
    A strong factor in not allowing many users to quit is addiction to the nicotine its self.  One must exam how to prevent addiction and ways to maintain abstinence from such by avoiding risky behavior and that that got them started.
    Key factors in successful cessation programs have been; self-report, team intervention, doctor assessment of problems and risks, follow up calls by a trained professional, and assessment of risks and possible ways of avoidant behaviors.
    It is now the purpose of this study to examine several factors.  One is to examine the point to which an individual is addicted through amount and frequency of use.  Secondly, to examine under what contexts does an individual chew under.  Third, to look at what situations hold a fascination with dipping and to why a user chooses to dip rather than a secondary option.
The second purpose of this study is to examine whether or not Nicorette gum provides a alternative to chewing tobacco and helps with withdrawal and craving.  The overall studies purpose will be based upon:  Is a new reinforcer needed to help chewers stop dipping within their context of use and Is situational context important in use and condition of dipping (size and frequency).

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Methods    

Subjects
   
    The study consists of 16 males between the ages of 18 and 22.  They all attend the small private catholic college of Saint Anselm in New Hampshire.  All have used chewing tobacco for several years and have self reported that they are addicted to chewing tobacco.  All participants want to quit to some degree, some wanting to quit for good and others realizing the disgusting habit and “believe” that they want to quit but are not that they can.

Procedure
  
     Participants were asked to take a survey once a week for three weeks, and those that would use Nicorette gum would be asked to do so in weeks 2 and 3.  The participants were also asked if they could be contacted in 6 months for a follow up to their success in quitting use of chewing tobacco.  The questionnaire was a revised Fagerstrom Questionnaire previously given to smokers.  Attached to the questionnaire was a self report sheet devised for looking at; under what conditions participants dip and how bad they crave chew and how the participant would react to the craving.  This was given during week one to establish a baseline as to the amount of dip used and how often it was taken.
    In week one each participant was met individually in their dorm room to be explained how to fill out the questionnaire and whether or not they were willing to participate for three weeks.
In week 2 the same questionnaire was given to the participants on an individual basis.  Individual exchange of the survey allowed for the researcher to answer any possible questions and extract more information from the self report section if it was too vague.  Some self-report information was then also guided in asking for specific reasons such as stress for increased tobacco use or why the participant did not feel like using the gum.
   Those that did not want to partake in using Nicorette were asked to quit on their own and continually record cravings and what they did to combat craving.  Users of Nicorette Gum were met individually and asked to use the gum twice a day.  They consented to use of the gum and to quit all other tobacco use.  Nicorette users were then asked to note when they used the gum, allocated two pieces a day with a weeks supply, and how it helped or did not help curve their craving for chewing tobacco.  
    In week 3 the same procedure was used as in week 2.  After the debriefing participants were asked if they could be contacted in 5 months and 1 week as to the success of their quitting chewing tobacco.  Users of the Nicorette were then informed if they wished to continue that they could contact their physicians to receive a prescription, however Nicorette gum is available over the counter if physician contact was unwarranted.
 

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Results                                                

     With the purpose of the study focusing on a fixed questionnaire and self-report, data was collect in three specific areas.  Situational cues were assessed with size and frequency of dips in a week in the questionnaire.  The first self-report section data was collected through rating craving and the reason for taking a dip.  The second self-report section examined craving into specific situations and personal reactions to those cravings.

Pearson’s Correlation  
 
    The questionnaire was based on a rating system with a scale of 1 to 7.  Situational cues were collected and compared to frequency in the day and week for dip and size of pinch when taken.  Significance was found in several areas with positive and negative correlations through a Pearson’s Correlation Test.
Alcohol intake and frequency of dips in a week is positively correlated, Pearson .812, sig. .001, n=14 as well as how often a participant chewed in a day is correlated with drinking .697, .012, 13. Playing video games and size and frequency in the day are positively correlated .707, .007, 14.  Playing sports was positively correlated with dips taken in a day, .637 .026 14.
     Social settings saw a correlation between social situations and dipping, while class time showed no occurrence of correlation.  Some correlation was found between after class and dips a day after week one, .699, and week two, .747, however week three was inconclusive and sporadic in nature.
     Instinctively one would assess that dips a week and dips a day would be positively correlated, which it was .755, .005, 14.  Frequency of dips a day and week were both correlated to size of dips by .812, .005, 14.
     Brand was negatively correlated to several aspects in users lives.  How often a week someone dipped was correlated by -.603, .021, 13 and dips a day -.634, .027, 13.  Situational cues seemed to correlate between brand and shower, -.742, .006, 14 as well as watching sports, -.755, .005, 13.
     Some other significance was found but varied from week to week in aspects; of wanting to dip in class and frequency, size of dip and several situations, and situations among themselves.  The data varied from week to week and seemed to be inconclusive.  It is note worthy is saying that there was some correlation, but due to variance from week to week is disregarded in aspect to significance in overall data.



Self-Report Data

     A good indicator of drive to quit can be seen in how long it took an individual to take their first three dips compared to their last dip taken as reported in their daily self-report.
 
    The graph indicates the variance in number of days between dips to their last day of dipping in the study.  If day three and last day dipped were equivalent, that expresses their final of day of use.
    It may not be clear as to whether an individual has cut back or necessarily reduced use from the graph when dip was taken.  It was however assessed from week 1 or base line week as compared to amount of use after week two and three. Participants were also compared as to their ability to cut back on use or abstain as to whether or not they used Nicorette gum, as shown in the table Reduction of Chewing Tobacco use.
   
    The graph clearly delineates the percentage of users that have reduce use and those that have not, and contrasted the two groups, gum users and non gum users.  The subject pool was small and may not be able to show significant reduction or abstinence to a larger pool, as for this study it opens the door or looking at various approaches to help cessation.

Self-Report Information              

    The self-report section gave an inner look into the participants causes of chewing tobacco at their specific time of use compared to craving.  Incite was also given into whether Nicorette is an effect means to help chewing tobacco users quit, as well as participants reasons for sticking with use of the gum.  Certain causes were also found to cause users to increase use in random situations throughout the week.
     Craving and dipping was assessed to be highest when chewing tobacco users were in the following situations; when they were stressed, when watching television, playing video games, and at a party.  These strong factors give reaffirmation to the belief of chewing tobacco to be a relaxant in stressful situations.  Using chewing tobacco at parties shows the need for an individual to fit in with others dipping and relieve anxiety of social settings. 
     It was also noted that in certain social contexts around peers, watching television and playing video games, that chewing tobacco was at its most used point. 
    Several users of Nicorette gum stopped after week two, three of five participants, due to the following factors; it tasted awful and they did not receive the same sensation as chewing tobacco.  Two participants that did not take the Nicorette in week 2 established that they had used the gum before and could not stand the taste.
    Those that stayed with the Nicorette said that the taste did not bother them.  Users of the gum also stated a strong drive to quit and want to have something to relieve their craving for tobacco.
    Several users seemed to be on task with their want to quit until certain situations came up.  Stress overall would cause some users to dip, whether from problems with a teacher, talking to others in a social setting such as a party, or family issues.  Studying for a test or writing a paper showed heightened amounts of use of chewing tobacco.
    Although the data collected was subjective and limited to the amount of truth through self-report, significant factors were found in varying areas.  A correlation to social and behavioral contexts was found with the amount and frequency of tobacco use.  Self-report data showed how frequently one took dips randomly and when an individual was actually ready to quit.  Incite was provided by self-report as to when users would defer back to use to help relieve stress and anxiety in varying situations.
 

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Discussion                                              

Findings

    The results have shown significance in several areas within the study relating to the hypothesis; Is a new reinforcer needed to help chewers stop dipping within their context of use and is situational context important in use and condition of dipping (size and frequency).  
     Looking at Nicorette users versus Self-Report users answered whether or not a new reinforcer is needed by exhibiting a higher succession rate in reduction and cessation of chewing tobacco than self-report users.  Nicorette gum did help some users quit which is shown with more success of users of the gum over non-users in cessation and reduction.  Those using gum took less random dips and showed an overall reduction in craving when using the gum over those trying to just quit.
    Social Context and dipping showed several key points in noting a significant correlation in situations where stress and alcohol were present.  When playing sports, chewing tobacco use rose significantly.  The positive correlation to social context shows a further need to examine the use of social context and behavior to address the problem of chewing tobacco.
    Some participants that reduced use of chewing tobacco seemed to fall into a relapse under stressful situations, social settings and peers.  Under the stress of school work many felt the need to use chewing tobacco to help calm them and establish a focus on doing work.  In social settings where others were dipping, peers and friends, relapse seemed significant.  A person’s willingness to quit was obverted when their roommate or close friends were still dipping.
    It is clear that two factors need to be addressed in a successful cessation program.  Factor one is the addressing of alternatives to dipping when stressed and a way to find focus when doing work.  Factor two is that an individual needs to avoid risky behavior of being around peers and friends that are still chewing.  A new setting must be established or their peers would have to quit with them.

Alternate Findings                            

    Nicorette gum help those that continued its use to reduce or even quit use of chewing tobacco.  Two participants using the gum, forty percent of gum users, and two users that previously tried Nicorette stopped use of the gum due to taste and lack of sensation.  To address the issue of taste it is recommended that future studies examine flavored Nicorette gum to help curve resistance.  Lack of feeling can be accounted by participants either not following directions for using the gum or desensitization to the lower amounts of nicotine in the gum.  4mg doses of Nicorette is available and maybe a more suitable solution, even though the nicotine in the 4mg gum is more likely to have a higher content of nicotine than dippers are receiving through chewing tobacco.
    Peer intervention is needed to help users quit.  If peers and friends are still using gum then those users trying to quit are extremely likely to have a relapse in use.  The social context issue is revisited and needs to be addressed in order for a user to be able to successfully quit.
    Not only is peer intervention needed but behavior plays an important role.  If an individual allows himself to placed into situations with chewing tobacco, they are likely to fall back into use.  Avoidance at practices and a need for NCAA rules of drug use on the field needs to be addressed.  When playing video games or in situations with alcohol users must find a new group to associate with or walk away when chewing tobacco is presented into the situation.

Future Practices Needed
   
    Assistance from medical personal is suggested in further studies.  Health Services should be informed and have an availability noted on the questionnaire so that users have a place to turn when advice or consultation is needed.
    More situations should be examined in the questionnaire.  Three blank spaces were provided and more situations users noted were; taking a shower, during excrement of bodily waste, driving, and getting ready to “go out” to party. Other questions that were left out of the study that could provide incite are; age started, where you started dipping, have you tried quitting before, and what is your drive to quit use.

Study Problems
  
     The study in its own right was successful in assessing situations in which use of chewing tobacco was prevalent, however the population size was not large enough to generalize findings to all users of chewing tobacco.  A larger population size would allow for a stronger correlation of data and a more complete study.
    Timing was limited in the study due to problems with the IRB.  Getting the study approved and covering possible dilemmas was difficult and needed to have been done last semester.  The hypothesis was refined over the summer and Nicorette gum was added in order to address the issue of craving and reinforcers.
    The length of the baseline was not long enough.  A baseline should have been established over two weeks to a month.  Dipping can vary due to situations and stress.  One week was not a realistic time frame to truly examine traditional use of chewing tobacco users.
Data collection was also minimized due to time constraints.  Data was collected and key points were noted, however reduction in use may take more than 2 weeks to notice.  A study should last at least three months with follow-ups after six months and one year.  A six month follow-up is possible, if time and effort allows the data will be collected
Conflicting opinions of teachers was another fault of the study.  Dealing with a professor in the field of study and a supervising teacher caused some conflict and stress on the study.  Overall teacher help was greatly appreciated and needed at times, however having two varying opinions can be too much to handle, especially when one is grading the paper and the other is trying to motivate you to do more.
 

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Thank You                                            

     I would loke to offer a thank you to all those that have helped me in doing my thesis.  I would to thank Professor Troisi for his help in establishing my project and guiding me through the stress of the IRB.  I would like to thank Dr. Connie Richards for her help with the IRB and guidance on the administration of Nicorette.  I would like to thank Professor Finn for his help in writing and analysising this thesis.  I would like to thank all the participants for their time and effort in participating in my study.  Thank You all for your help and support.-Alaska

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References                                                

Saint Anselm College
APA
Smokeless Tobacco Home Page