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Intervention Summary

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Enough Snuff

Enough Snuff is a self-help, self-paced tobacco cessation program for individuals who use smokeless tobacco (e.g., moist snuff, chewing tobacco) but want to quit the use of smokeless tobacco or all tobacco products entirely. The program was developed on the basis of a cognitive behavioral model.

Participants receive the following materials from the program implementer, usually via mail:

  • A 60-page self-help guide for quitting smokeless tobacco, which is organized around four key steps: (1) evaluating readiness and motivation to quit, (2) setting a quit date and selecting a quit plan, (3) dealing with withdrawal symptoms, and (4) maintaining quit status. The guide also includes self-test measures of motivation and readiness to quit.
  • A 20-minute companion DVD, which highlights the key steps for quitting smokeless tobacco and provides encouraging testimonials from people who have successfully quit using smokeless tobacco through Enough Snuff. The DVD also provides specific reasons for quitting and techniques to quit successfully.

In addition, each participant receives at least two 10- to 15-minute supportive phone calls from a tobacco cessation counselor. During the first phone call, which occurs approximately 1 week after materials are mailed, the participant is encouraged to articulate reasons for quitting, choose a quit method, and select a quit date. Subsequent phone calls, which are timed to correspond with the participant's selected quit date, typically focus on helping the participant deal with withdrawal symptoms and think of "slips" as learning experiences instead of failures.

In one study reviewed for this summary, participants received a version of Enough Snuff that was modified for use with military personnel. In all studies, the population was entirely or almost entirely composed of male participants.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: July 2013
1: Abstinence from smokeless tobacco use
2: Abstinence from all tobacco use
3: Attempts to quit smokeless tobacco use
4: Use of recommended cessation techniques
Outcome Categories Tobacco
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Race/ethnicity unspecified
Settings Home
Workplace
Geographic Locations Rural and/or frontier
Implementation History The Enough Snuff self-help cessation guide was first published in 1992 and is now in its eighth edition. The program has been used by approximately 50,000 individuals in all 50 States and in Canada.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations Implementation materials have been adapted for use with American Indians and military personnel, and a Spanish version of the program (¡Basta Ya! de Rapé) is available.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: July 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Severson, H. H., Andrews, J. A., Lichtenstein, E., Danaher, B. G., & Akers, L. (2007). Self-help cessation programs for smokeless tobacco users: Long-term follow-up of a randomized trial. Nicotine and Tobacco Research, 9(2), 281-289.  Pub Med icon

Severson, H. H., Andrews, J. A., Lichtenstein, E., Gordon, J. S., Barckley, M., & Akers, L. (2000). A self-help cessation program for smokeless tobacco users: Comparison of two interventions. Nicotine and Tobacco Research, 2(4), 363-370.  Pub Med icon

Study 2

Cigrang, J. A., Severson, H. H., & Peterson, A. L. (2002). Pilot evaluation of a population-based health intervention for reducing use of smokeless tobacco. Nicotine and Tobacco Research, 4(1), 127-131.  Pub Med icon

Study 3

Severson, H. H., Peterson, A. L., Andrews, J. A., Gordon, J. S., Cigrang, J. A., Danaher, B. G., et al. (2009). Smokeless tobacco cessation in military personnel: A randomized controlled trial. Nicotine and Tobacco Research, 11(6), 730-738.  Pub Med icon

Outcomes

Outcome 1: Abstinence from smokeless tobacco use
Description of Measures In two studies, abstinence from smokeless tobacco use was measured using an item that asked participants to report 7-day point prevalence, that is, whether they had not used any smokeless tobacco in the past 7 days (i.e., "had not used chew/snuff" at all, "not even one dip or chew"). Participants who reported that they had not used smokeless tobacco during the past 7 days were considered to be abstinent from smokeless tobacco use.

In a third study, prolonged smokeless tobacco abstinence was measured using an item at both the 3-month follow-up assessment (i.e., "Have you used smokeless tobacco at all during the past 3 months?") and the 6-month follow-up assessment (i.e., "Have you used smokeless tobacco at all during the past 6 months?"). Participants who reported that they had not used smokeless tobacco during the item's timeframe were considered to be abstinent from smokeless tobacco use.
Key Findings In one study, participants who used smokeless tobacco were randomly assigned to the intervention or comparison group. Participants in the intervention group received the Enough Snuff program, and those in the comparison group received only the self-help guide for quitting smokeless tobacco. At the 6-month follow-up, the percentage of participants who were abstinent from smokeless tobacco use was higher in the intervention group than in the comparison group (23.4% vs. 18.4%; p < .05).

In another study, active-duty military personnel who acknowledged current use of smokeless tobacco during a required annual preventive health screening were randomly assigned to the intervention or control group. Participants in the intervention group received the Enough Snuff program, and those in the control group received usual care (i.e., they were encouraged to consider quitting and were provided with information on how to sign up for an 8-week tobacco cessation class). At the 3-month follow-up, the percentage of participants who were abstinent from smokeless tobacco use was higher in the intervention group than in the control group (41% vs. 17%; p = .041). At the 6-month follow-up, the difference in abstinence from smokeless tobacco use between the intervention and control groups was not significant; there also was no significant between-group difference for abstinence from smokeless tobacco use at two or more consecutive follow-up assessments.

In a third study, active-duty military personnel who acknowledged current use of smokeless tobacco during an annual dental examination were randomly assigned to the intervention or control group. Participants in the intervention group received a version of the Enough Snuff program that was modified for use by military personnel, and those in the control group received usual care (i.e., they participated in standard procedures that are part of the annual dental examination, including receiving recommendations to quit using smokeless tobacco and a referral to extant local tobacco cessation programs). Analysis accounted for the clustering of participants within military bases. The percentage of participants who were abstinent from smokeless tobacco use was higher in the intervention group than in the control group at the 3-month follow-up (20.4% vs. 9.2%; p < .001) and the 6-month follow-up (13.5% vs. 5.6%; p < .001).
Studies Measuring Outcome Study 1, Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 2: Abstinence from all tobacco use
Description of Measures In one study, abstinence from all tobacco use was assessed by items that asked participants to report 7-day point prevalence, that is, whether they had not used any smokeless tobacco (i.e., "had not used chew/snuff" at all, "not even one dip or chew") and whether they had not smoked during the past 7 days. Participants who reported that they had not used smokeless tobacco and had not smoked during the past 7 days were considered to be abstinent from all tobacco use.

In another study, abstinence from all tobacco use was assessed by items that asked participants to report whether they "used smokeless tobacco at all in the past 7 days" and to "describe their cigarette smoking (cigar or pipe smoking) during the last 30 days." Participants who reported that they had not used smokeless tobacco in the past 7 days and had no use of other tobacco products in the past 30 days were considered to be abstinent from all tobacco use.
Key Findings In one study, participants who used smokeless tobacco were randomly assigned to the intervention or comparison group. Participants in the intervention group received the Enough Snuff program, and those in the comparison group received only the self-help guide for quitting smokeless tobacco. Findings indicated the following:

  • At the 6-month follow-up, the percentage of participants who were abstinent from all tobacco use was higher in the intervention group than in the comparison group (31.5% vs. 23.4%; p < .05).
  • At the 12-month follow-up, the difference in abstinence from all tobacco use between the intervention and comparison groups was not significant.
  • However, at the 12-month follow-up, the percentage of participants who were abstinent from all tobacco use at two or more consecutive follow-up assessments was higher in the intervention group than in the comparison group (22.9% vs. 16.1%; p < .05).
In another study, active-duty military personnel who acknowledged current use of smokeless tobacco during an annual dental examination were randomly assigned to the intervention or control group. Participants in the intervention group received a version of the Enough Snuff program that was modified for use by military personnel, and those in the control group received usual care (i.e., they participated in standard procedures that are part of the annual dental examination, including receiving recommendations to quit using smokeless tobacco and a referral to extant local tobacco cessation programs). Analysis accounted for the clustering of participants within military bases. The percentage of participants who were abstinent from all tobacco use was higher in the intervention group than in the control group at the 3-month follow-up (25.3% vs. 8.1%; p < .001), the 6-month follow-up (24.0% vs. 12.0%; p < .001), and both the 3- and 6-month follow-up assessments (17.6% vs. 4.6%; p < .001).
Studies Measuring Outcome Study 1, Study 3
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 3: Attempts to quit smokeless tobacco use
Description of Measures Participants were asked to report their tobacco use in the 6 weeks since enrollment in the study. Participants who continued to use smokeless tobacco were then asked whether they had made a serious attempt to quit smokeless tobacco use (i.e., quitting for at least 24 hours).
Key Findings Participants who used smokeless tobacco were randomly assigned to the intervention or comparison group. Participants in the intervention group received the Enough Snuff program, and those in the comparison group received only the self-help guide for quitting smokeless tobacco. At the 6-month follow-up, the percentage of participants who continued to use smokeless tobacco but made at least one serious attempt to quit was higher in the intervention group than in the comparison group (81% vs. 69%; p < .01).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 4: Use of recommended cessation techniques
Description of Measures Use of recommended cessation techniques was assessed by items that asked participants to report whether they did each of the following since enrolling in study: set a quit date, wrote down reasons for quitting, told family and friends that they planned to quit, asked a supporter to read the manual, made a plan for dealing with tough situations, and used an alternative to chewing tobacco (e.g., nicotine gum, nicotine patch, chewing gum, candy, sunflower seeds or nuts, herbal or mint snuff, Zyban).
Key Findings Participants who used smokeless tobacco were randomly assigned to the intervention or comparison group. Participants in the intervention group received the Enough Snuff program, and those in the comparison group received only the self-help guide for quitting smokeless tobacco. Findings indicated the following:

  • At the 6-week follow-up, participants in the intervention group were more engaged in using various cessation techniques than participants in the comparison group: setting a quit date (p < .001), writing down reasons for quitting (p < .05), telling family and friends (p < .05), planning for tough situations (p < .001), and using an alternative product as a cessation aide (p < .001). Participants' use of the following alternative products as a cessation aide was greater for the intervention group than the comparison group: chewing gum (p < .001), candy (p < .01), sunflower seeds or nuts (p < .001), and herbal or mint snuff (p < .01).
  • At the 12-month follow-up, participants in the intervention group were more engaged in using various cessation techniques than participants in the comparison group: setting a quit date (p < .001), writing down reasons for quitting (p < .05), telling family and friends (p < .05), planning for tough situations (p < .001), and using an alternative product as a cessation aide (p < .01). (Results for each alternative product were not reported.)
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
97% Male
3% Female
95% White
3% American Indian or Alaska Native
2% Race/ethnicity unspecified
Study 2 18-25 (Young adult)
26-55 (Adult)
100% Male 100% Race/ethnicity unspecified
Study 3 18-25 (Young adult)
26-55 (Adult)
99.9% Male
0.1% Female
89% White
3.8% Hispanic or Latino
2% Race/ethnicity unspecified
1.9% Black or African American
1.5% American Indian or Alaska Native
1.2% Asian
0.6% Native Hawaiian or other Pacific Islander

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Abstinence from smokeless tobacco use 3.0 3.0 3.1 2.8 3.0 3.5 3.1
2: Abstinence from all tobacco use 3.3 3.3 3.0 2.8 2.8 3.5 3.1
3: Attempts to quit smokeless tobacco use 1.5 2.8 2.8 3.0 2.5 3.5 2.7
4: Use of recommended cessation techniques 1.3 3.0 2.5 3.0 2.5 3.8 2.7

Study Strengths

The measures used to assess self-reported abstinence from all tobacco use are standard and have been shown to have adequate reliability and validity by other investigators. There is face validity for attempts to quit smokeless tobacco use and for use of recommended cessation techniques. There is little opportunity for variability in the implementation of the mailed guide and DVD. In one study, almost all participants reported that they read the guide, and most participants in the intervention group reported that they watched the DVD. In another study, tobacco cessation counselors received training, used written prompt sheets, and received weekly feedback from one of the investigators, and calls by counselors were recorded and reviewed by a supervising psychologist. In one study, there was no difference in attrition rate between intervention and comparison groups, and in another study, the attrition rate was low. All studies used a conservative intent-to-treat model as a method to manage missing data. Randomization of participants to the study conditions minimized confounding variables. In two of the studies, sample sizes were large and provided adequate power. Data analyses were appropriate for all three studies.

Study Weaknesses

The reliability of measures for attempts to quit smokeless tobacco use and use of recommended cessation techniques was not addressed. In two of the studies, there was no monitoring or measurement of fidelity of the supportive phone calls and very limited discussion of the nature of the training received by the counselors. In one study, the percentage of participants who read the guide or watched the DVD at least once was not reported. Although phone calls were reviewed by a supervisor in one study, there was no fidelity check on adherence to the basic elements of the intervention and no report of the types of fidelity problems encountered or how often interviewers were counseled for not following protocol. In two studies, there was considerable attrition across the assessments; there also were a few differences between study completers and dropouts, especially in one of the studies, where there were differences in potential confounding variables such as current smoking, attempts to quit, and use of smokeless tobacco. Also in this study, although it is reasonable to expect that participants in the intervention and control groups had a similar health status and attitudes, these potential confounding variables were not mentioned or controlled for. The sample size for one study was small and may not have been adequate for detecting significant between-group differences.

Readiness for Dissemination
Review Date: July 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Oregon Research Institute. (2011). Enough Snuff: A video program to help you quit spit tobacco [DVD]. Scotts Valley, CA: ETR Associates.

Oregon Research Institute. (2011). Self help lozenge, my last dip: Telephone coaching protocol. Eugene, OR: Author.

Severson, H. H. (2002). Enough Snuff: Pocket guide for quitting smokeless tobacco. Scotts Valley, CA: ETR Associates.

Severson, H. (2010). Smokeless tobacco: Risks, challenges, and opportunities. [PowerPoint slides]. Eugene, OR: Author.

Severson, H. H., & Gordon, J. S. (2008). Enough Snuff: A guide for quitting smokeless tobacco (8th ed.). Scotts Valley, CA: ETR Associates.

Severson, H. H., & Gordon, J. S. (2012). Enough Snuff--Quitting smokeless tobacco: A guide for military personnel (3rd ed.). Scotts Valley, CA: ETR Associates.

Severson, H. H., Gordon, J. S., & Christiansen, S. (2010). Tough enough to quit: A video program to help you quit spit tobacco [DVD]. Scotts Valley, CA: ETR Associates.

Additional documents:

  • Counseling Calls Outline and Script Menu for Group #2 LASH
  • Enough Snuff Goals for Training Curriculum
  • Smokeless Tobacco User Survey

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 3.0 3.8 3.3

Dissemination Strengths

The DVDs feature diverse individuals telling personal stories in straightforward and compelling ways. A list of resources that support intervention participants is provided in the program guides. The developer can customize the presentation and training on the basis of the implementer's needs. The PowerPoint slides used for training are informative and of high quality. The straightforward assessment tools can easily be used to track outcomes by facilitating participants' self-assessments. The detailed phone scripts and protocol support quality assurance by providing clear guidance on how to respond to several different scenarios during implementation.

Dissemination Weaknesses

The lack of a program Web site may hinder users looking for readily accessible information on program implementation and available training and consultation. Materials for tobacco cessation counselors contain a few typographical errors, as well as information that might be too specific for general implementation.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Enough Snuff: A Guide for Quitting Smokeless Tobacco
  • $11.95 for 1 guide
  • $547.50 for 50 guides
  • $895 for 100 guides
Yes
Enough Snuff: Pocket Guide for Quitting Smokeless Tobacco (set of 10) $10 per set Yes
Enough Snuff: A Video Program To Help You Quit Snuff or Chew (DVD) $49.95 each Yes
¡Basta Ya! de Rapé (Spanish version of Enough Snuff: A Guide for Quitting Smokeless Tobacco)
  • $11.95 for one guide
  • $547.50 for 50 guides
  • $895 for 100 guides
Yes, if implementation is with a Spanish-speaking population
Enough Snuff--Quitting Smokeless Tobacco: A Guide for Military Personnel
  • $11.95 for 1 guide
  • $547.50 for 50 guides
  • $895 for 100 guides
Yes, if implementation is with a military population
Tough Enough To Quit: A Video Program To Help You Quit Spit Tobacco (DVD) $49.95 each Yes, if implementation is with a military population
Enough Snuff: A Guide for Quitting Smokeless Tobacco for American Indians
  • $11.95 for 1 guide
  • $547.50 for 50 guides
  • $895 for 100 guides
Yes, if implementation is with an American Indian population
Enough Snuff: A Video Program To Help American Indians Quit Spit Tobacco (DVD) $49.95 each Yes, if implementation is with an American Indian population
Half-day, on-site training $1,000 plus travel expenses No
All-day, on-site training $2,000 plus travel expenses No
Off-site consultation with developer via phone or Skype $500-$1,000, depending on site needs No
Measure for baseline and follow-up assessments Free, by request No
Contact Information

To learn more about implementation or research, contact:
Herbert H. Severson, Ph.D.
(541) 484-2123
herb@ori.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):