Godfather Technical Discussion

Behavior Change Prescription

Earlier this summer I was given an assignment covering the Health Belief Model. The model, from social psychologists at the U.S. Public Health Service, attempts to measure five variables that may predict the success a person will have in making a behavior change. During the course of completing that assignment, I made a decision to incorporate a change in my own behavior and test the Health Belief Model.

For almost thirty years I have been using smokeless tobacco on a daily basis. At the time I made the decision to quit, I consumed, on average, 8 cans (272g) of snuff per week. From past experiences I knew that quitting without a plan was only a formula for failure. Using the lessons learned from past failures as well as new ideas learned in researching my addiction, I was determined to quit.

I began with (what was for me) the most obvious source of information on the subject, the American Cancer Society (ACS). Their booklet, "Quitting Spit (Smokeless) Tobacco", was a valuable beginning point. This booklet discusses who uses smokeless tobacco (predominately white males and more than 1/3 of professional baseball players) as well as some of the factors influencing young people to start. Although I am no longer "young", I recognize many of these factors from my youth, such as:

* Peer pressure

* Local lifestyles and fashions

* Examples set by teachers and staff

The booklet also listed many of the dangers of smokeless tobacco use. The most serious of which is an increased risk of cancer of the mouth and throat. According to the ACS, these cancers are much more common among snuff users than in non-tobacco users. Other adverse health risks noted were:

* Addiction to nicotine

* Leukoplakia (white sore in the mouth that are precursors to cancer)

* Gum recession

* Bone loss around the teeth

* Abrasion of the teeth

* Staining of the teeth

* Bad breath

After so many years, many of the preceding facts were already known to me but still had not convinced me to (or how to) quit. The ACS's booklet has a very informative section on nicotine and its addictive qualities.

Nicotine is a drug that is naturally occurring in tobacco and has been labeled as addictive as heroin or cocaine. The addiction is as psychological as it is physical. Any plan to quit must overcome both of these addictions to be successful.

According to the ACS, "Spit tobacco delivers a high dose of nicotine. An average dose for snuff is 3.6 milligrams (mg) and for chewing tobacco is 4.6 mg - compared to 1.8 mg for cigarettes. Blood levels of nicotine throughout the day are similar among smokers and those who use smokeless tobacco."

If the booklet came up short in any one area, it was in the "How to Quit" section. The information provided wasn't so much a "How To" as opposed to a list of possible features to include in a quitting plan. The help listed for psychological addiction included:

* Telephone based help programs

* Support of family and friends

* Quitting programs

* Tobacco Cessation groups and classes

The physical addiction was also scantily covered with only a listing of various nicotine replacement therapies and a few nicotine prescription drugs used to counter withdrawal.

Most surprising about the ACS's booklet was the reference to the Health Belief Model and the Stages of Change Model:

Quoting from the booklet:

The Health Belief Model says that you will be more likely to stop tobacco use 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 tobacco use; or

* know of someone who has had health problems as a result of their tobacco use

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

* Pre-contemplation: At this stage, the tobacco user is not thinking seriously 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 and take steps to avoid it.

The most compelling non-health argument made for quitting is a reminder of the monetary cost of tobacco use. Not only is the future cost discussed, but it is brought to the forefront by reminding the reader to calculate the cost from previous use.

A much more informative book a developing a plan for quitting came from the National Institutes of Health (NIH) with Spit Tobacco: A Guide for Quitting. The book began with many of the myths and truths about smokeless tobacco. This is useful because, as the book points out, the myths can make people comfortable in their habits, decreasing the chances for success. The most important myth is that smokeless tobacco is a harmless alternative to smoking. Smokeless tobacco is still tobacco. The same cancer-causing chemicals are used to cure smokeless tobacco as are for cigarette tobacco. The Surgeon General makes this very clear:

"No matter what you may hear today or read in press reports later, I cannot conclude that the use of any tobacco product is a safer alternative to smoking. This message is especially important to communicate to young