A Dental-Based, Athletic Trainer-Mediated Spit Tobacco Cessation Program for Professional Baseball Players

By Margaret M. Walsh, EdD;
John C. Greene, DMD, MPH;
James A. Ellison, DDS, MPH;
Mark A. Letendre, ATC; and
Ned Bergert, ATC

During 1997 spring training, the National Spit Tobacco Education Program provided a spit (smokeless) tobacco intervention program to 16 professional baseball clubs. The program consisted of an awareness-raising presentation and an opportunity to discuss quitting spit tobacco use with an expert cessation counselor. For two clubs, however, a more extensive intervention was pilot-tested for feasibility and acceptability among their major- and minor-league teams during their regularly scheduled health examinations at the beginning of spring training. The intervention included an oral exam by a dentist who advised spit tobacco users to stop and pointed out any spit tobacco-associated lesions in the player's mouth, brief cessation counseling by a specially trained dental hygienist, and ongoing support and follow-up by the certified athletic trainer to promote cessation. Findings from this pilot study indicate that this intervention, which is dependent upon involvement of dental professionals, was feasible to implement during spring training and appeared to be well-received by the athletes. Dental professionals are in an excellent position to advise and help spit tobacco users to quit and can have an important role in helping youth overcome this rapidly growing addiction.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

During spring training in 1997, the National Spit Tobacco Education Program (NSTEP), funded by the Robert Wood Johnson Foundation and operated by Oral Health America, collaborated with the athletic trainers in professional baseball to provide a spit tobacco intervention program to 16 professional baseball clubs, eight in Arizona and eight in Florida. The goals were to generate awareness about the hazards of spit tobacco and to motivate players to quit tobacco use. These awareness-raising sessions were presented by Joe Garagiola, Baseball Hall of Fame broadcaster, former major-leaguer, and national chairman for NSTEP; Bill Tuttle, former major-leaguer and victim of a spit tobacco-related oral cancer; and Tuttle's wife, Gloria Tuttle. Following their presentations, all major- and minor-league athletes on these 16 clubs were offered an opportunity for individual counseling with an expert spit tobacco cessation counselor, and the athletic trainers were provided with a brief in-service training on nicotine replacement therapy, self-help cessation strategies, and a toll-free telephone number for follow-up consultation with an expert cessation counselor as needed.

For two clubs in Arizona, however, a more extensive trainer-mediated, dental-based intervention was provided to members of their two major-league teams and their 10 associated minor-league teams over a period of 11 days. This extended intervention was offered to these two clubs as a pilot test to determine the feasibility of its implementation and its acceptability to athletes and athletic trainers. The intervention consisted of an additional training component for the athletic trainers, to prepare them to assume a more active role in helping athletes with their cessation efforts, and a dental component. The dental component included an oral mucosal examination by a dentist who pointed out spit tobacco-associated tissue damage in a user's own mouth and advised him to quit his tobacco use, a brief cessation counseling session by a dental hygienist on ways to get ready to quit and to cope with cravings and situations that trigger spit tobacco use, and ongoing support and follow-up by the athletic trainer. This article describes this pilot athletic trainer/dental component and reports the results.

Methods

Recruitment and Training

In January 1997, the head certified athletic trainers of the San Francisco Giants and the Anaheim Angels major-league baseball teams agreed to collaborate with researchers from the University of California at San Francisco in providing an oral cancer screening examination by a dentist and brief spit tobacco cessation counseling by a dental hygienist for all club members during their regularly scheduled health examinations at the beginning of spring training in Arizona. All certified athletic trainers associated with each club received additional training on site in behavioral methods and nicotine replacement therapy to assist an athlete's quit attempt. Athletic trainers were encouraged to provide ongoing support and motivation during the quitting process and were given the toll-free telephone number of an expert cessation counselor as a resource in the event that an athlete needed more intensive problem-solving and supportive treatment.

To deliver the dental component, two Arizona-based dentist and dental hygienist teams were recruited. They were trained in a two-hour session on the negative health effects of spit tobacco use, how to identify and assess the severity of spit tobacco-associated oral lesions, the oral exam protocol (Table 1), the common elements of spit tobacco cessation counseling, an overview of how the nicotine patch system and nicotine gum work, indications and contraindications for use of nicotine replace therapy, instructions for use of the therapy, how to assess signs and symptoms of nicotine withdrawal and toxicity, and side effects of therapy and what to do when they appear. Throughout the training, the importance of confidentiality and the need to ignore the celebrity status of individual athletes (i.e., no autographs or photographs) were emphasized.

During delivery of the intervention, the dentist-hygienist teams were paired on site with an experienced dentist-hygienist team from UCSF. This was done to provide on-site mentoring to ensure quality control and efficiency in implementing the program and to begin to establish an infrastructure of Arizona-based dentists and hygienists who could help sustain the program if it became institutionalized by professional baseball for subsequent spring trainings.

Program Protocol

Participation in the program was voluntary and in accordance with UCSF and federal human subjects guidelines. All athletes who agreed to participate completed a consent form; a confidential health history; and a brief two-page questionnaire to assess their spit tobacco use status and, for users, their patterns of use, their previous attempts to quit and methods they used, their interest in receiving help to quit, and their interest in using nicotine replacement therapy. After these baseline assessments, each athlete was given a brief dental inspection to identify those in obvious need of professional dental care so as to avoid major dental problems during the season. Athletes who appeared to be in need of dental care were identified to their athletic trainers.

This brief dental inspection was followed by an oral cancer screening examination. All athletes screened, regardless of spit tobacco use status, were informed orally and in writing of any oral mucosal lesions and were scheduled for follow-up by the athletic trainer and/or club dentist. Nonusers of spit tobacco were encouraged to remain tobacco free and asked to be supportive of teammates trying to quit. For each user, the dentist pointed out in the athlete's mouth any problems associated with spit tobacco use. The athlete was actively involved in this examination process as a way to increase his personal involvement in the health effects of his behavior. Spit tobacco-using athletes without oral problems were shown pictures of other athletes' mouths showing spit tobacco-related oral disease. Emphasis was placed on the similarity of the subject in the picture to the athlete being examined and on the action-consequence relationship. To maintain his involvement, each user was given a disposable mouth mirror to watch for signs of disease. In addition, the dentist advised the athlete to quit using all forms of tobacco, offered assistance with the spit tobacco quitting process on that day, and provided each user with a copy of a printed self-help guide to quitting spit tobacco use titled either "Beat the Smokeless Habit -- Game Plan for Success"1 or "Enuff Snuff."(2)

After the oral cancer screening examination, the dentist sent all spit tobacco users who wished to quit their tobacco habits to the hygienist on site for personal instruction on setting a quit date and developing a plan to get ready to quit and to cope with cravings and triggers for use. They were also given self-help guides and sample oral non-tobacco substitutes, and were screened to determine their eligibility for nicotine replacement therapy in the form of nicotine gum and/or a nicotine patch system. For those who were eligible for replacement therapy, the hygienist explained the purpose, methods, risks, and benefits of using the therapy; answered questions; provided the athlete with a toll-free telephone number for follow-up consultation with an expert spit tobacco cessation counselor; and referred him to the athletic trainer for additional help with and monitoring of his quit attempt. An expert cessation counselor was present during the oral exam and brief counseling program to observe and provide support if needed.

After completing the dental component, the dentist and hygienist, along with the expert cessation counselor, met with the athletic trainers to identify those athletes who had oral lesions in need of follow-up and those who had decided to quit their spit tobacco use, set a quit date and had a plan for getting ready to quit and for coping with the quitting process. Quit date and copies of the quit plan were shared with the certified athletic trainers so they could provide ongoing support and encouragement.

At the end of the season, the certified athletic trainers of both clubs reported on the number of players who actually quit their spit tobacco use and provided feedback regarding aspects of the program that were perceived as most helpful.

Results

Prevalence and Patterns of Spit Tobacco Use

A total of 304 athletes (99 major-leaguers and 205 minor-leaguers) of the two professional baseball clubs participated in the program, representing about 87 percent of the available club members present at spring training.

Based on self-reports, there were 95 current spit tobacco users (31 percent), 22 former users (7 percent), and 187 nonusers (62 percent). Among the current users, 61 (64 percent) were daily users, 20 (21 percent) were weekly users, and 14 (15 percent) reported using two to three times a month. The weekly and monthly spit tobacco users were combined for analysis into "social" users, since they reported use of spit tobacco more than once a month, but not every day. Table 2 shows the characteristics of users overall and stratified by daily and social users. Overall, 56 percent of current spit tobacco users had used it for five or more years, and 14 percent for more than 10 years. The median duration of use was five years. More than half of the users (53 percent) reported using spit tobacco seasonally rather than year-round.

Most spit tobacco users (71 percent) reported using snuff exclusively. When all current users were asked what brand they usually used, most (47 percent) reported Copenhagen, a high-nicotine brand of snuff. About two-thirds of users (71 percent) reported keeping a dip or chew in their mouth for more than 10 minutes at a time, and 24 percent reported using spit tobacco at least five times a day.

Compared to social users, daily users were more likely to be year-round users, to use spit tobacco more than five times a day, to keep the tobacco in their mouth for more than 20 minutes at a time, to have used for five or more years, and to report use of Copenhagen.

Prevalence of Oral Lesions

Although all 304 athletes completed the questionnaire, only 253 of them agreed to have an oral examination. Among the 95 spit tobacco users examined, 53 (56 percent) had spit tobacco-associated oral mucosal lesions. Of these athletes, 41 (77 percent) were daily users, and 12 (23 percent) were social users.

Interest in Quitting

Strategies used in previous quit attempts by the 95 current users included "cold turkey" (55 percent), use of oral substitutes such as mint snuff (33 percent) or gum and seeds (28 percent), use of the nicotine patch (6 percent), and use of nicotine gum (5 percent). Almost half of all spit tobacco users (47 percent) reported at least one previous quit attempt (Table 3). Fewer than half (45 percent) expressed on the baseline questionnaire that they would like help quitting that day. Immediately after the oral exam, however, 71 percent (N=68) actually sought cessation counseling with the hygienist. Almost half of those athletes who were counseled (49 percent) set a quit date. About a third of all spit tobacco users (N=31) expressed interest in the nicotine patch to aid them in their quit attempt, and 18 percent (N=17) wished to learn about the nicotine spray. More daily users than social users had previously tried to quit (54 percent vs. 35 percent), expressed a desire for help to quit prior to the oral exam (58 percent vs. 24 percent), wanted to learn more about nicotine replacement therapy (patch: 41 percent vs. 18 percent; spray: 25 percent vs. 6 percent), actually sought counseling (82 percent vs. 50 percent), and set a quit date (48 percent vs. 15 percent).

Motivating Factors

Overall, the most commonly mentioned reasons for trying to quit given by users who sought counseling immediately after the oral exam were concerns about health (21 percent), family (10 percent), and addiction (5 percent).

During cessation counseling, users identified situations that increase risk of using spit tobacco. Use "after a meal" and "when waiting around bored" were the two trigger situations most often cited. Situations mentioned solely by daily users were "before going to bed," "first thing in the morning," and "driving in a car." Use of nontobacco oral substitutes was the most common coping strategy identified by users during counseling (58 percent) and the only one mentioned by social users. Daily users also cited nicotine replacement (18 percent), tapering down use (10 percent), doing something else such as exercising or reading (6 percent), using toothpicks or after dinner mints (4 percent) after a meal, chewing on cups or straws (4 percent), and use of a support group (2 percent).

Athletic Trainer Feedback

Of 67 users who sought counseling after the oral exam, 6 (9 percent) were reported by their athletic trainers at the end of the season to have quit. The certified athletic trainers for both clubs studied cited feedback from the oral exam, nicotine replacement, support from team players and family, and use of alternative behaviors to avoid high-risk situations as quitting techniques that seemed to be particularly useful. They mentioned, however, a need for nicotine replacement products in the clubhouse and for information on the use of other pharmacologic treatments. They also cited the motivational message presentation, the oral examination by the dentist, and the expert counselor's meeting with players as the most helpful parts of the NSTEP program for helping players quit spit tobacco.

Discussion

To counteract the link between baseball and spit tobacco use, Major League Baseball has participated in a variety of activities to decrease use in professional baseball. For example, in 1990 Major League Baseball joined forces with the Professional Baseball Athletic Trainers Society (PBATS), the National Cancer Institute, and the Fox Chase Cancer Center in a full-scale educational campaign to teach professional baseball players and team personnel about the long-term hazards of using spit tobacco.(3) They worked together to publish Beat the Smokeless Habit1 (a 16-page guide tailored to baseball athletes to help users break their spit tobacco addiction), an athletic trainer's cessation manual,(4) and clubhouse posters. These materials were distributed to all major- and minor-league players early in the 1991 baseball season. In 1993, a formal ban against spit tobacco use in minor-league baseball was instituted,(5,6) but no consistent program to help individual professional baseball athletes trying to quit was put into place. During 1995 and 1996, major-league players working with the NSTEP partner, Romano and Associates, appeared in antitobacco public service announcements. Moreover, under the leadership of Joe Garagiola, the national chairman of NSTEP, NSTEP has provided awareness-raising presentations on the health risks of spit tobacco use to every professional baseball club since 1996. Nevertheless, spit tobacco use is still viewed in televised Major League Baseball games and in ballparks.

Findings from this pilot study are encouraging in that they indicate that it is feasible to include an oral exam with feedback, advice to quit, and brief cessation counseling as part of the annual physical exam provided to professional baseball players at the beginning of spring training. Moreover, having done so was acceptable to both players and athletic trainers in the two clubs studied. The unknown is how representative these two clubs are of the 30 in existence, since the athletic trainers in the pilot study were knowledgeable about the hazards of spit tobacco use; willing to help implement the dental component; and motivated to provide support, encouragement, and nicotine replacement therapy to those athletes attempting to break their tobacco addiction. It seems reasonable to assume, however, that they do resemble other professional athletic trainers in baseball, since PBATS has sponsored many speakers over the years to increase professional baseball's awareness of the negative health effects of spit tobacco use;(7-9) and, in 1995, PBATS representatives provided testimony before the U.S. House Subcommittee on Health and the Environment about the addictive nature of spit tobacco.(10)

The finding on the baseline questionnaire that 45 percent (N=43) of the athletes expressed interest in quitting their tobacco use and 47 percent (N=45) reported a previous quit attempt is consistent with reports from a 1992 survey of four rookie and short-season single "A" leagues (N=905) indicating that 63 percent of users reported they wanted to quit and 40 percent said they had tried to quit unsuccessfully.(11) These data indicate that many baseball athletes want to quit but need help with the process.

The fact that 71 percent (N=67) of spit tobacco users in this pilot study sought cessation counseling with the hygienist immediately after the oral exam suggests that the exam procedure motivated additional athletes to seek help to stop their tobacco use. This finding is consistent with three recent studies of spit tobacco cessation interventions delivered by dental professionals in the course of routine care,(12 )at college athletic facilities,(13) and at professional baseball stadiums during the season on a game day.(14)

In the first study,12 dental patients who used spit tobacco daily were randomly assigned either to usual care or to usual care plus intervention -- which consisted of an oral mucosal examination with special attention to oral lesions, cessation advice, a self-help manual, a nine-minute videotape, a brief counseling session with the dental hygienist, setting a quit date, a follow-up telephone call, and follow-up mailings. Compared to subjects in the usual-care group, more subjects in the intervention group reported abstinence from spit tobacco at three months (32 percent vs. 21 percent, P<0.01) and at 12 months (18 percent vs. 13 percent, P <0.01).

In the second study,(13) a similar spit tobacco cessation intervention delivered by a dentist-hygienist team was tested among male college baseball and football athletes in a randomized controlled trial conducted in 16 California colleges. Unlike the previous study,(12) this study included spit tobacco users who reported regular but relatively low frequency of tobacco use (two to three times a month) in addition to daily users. The intervention included an oral exam and advice to quit by a dentist who pointed out spit tobacco-associated oral lesions in the athlete's mouth or in pictures of the mouths of similar-aged athletes, showed graphic pictures of facial disfigurement due to oral cancer, and provided a self-help guide;(1) a single 15- to 20- minute cessation counseling session with a hygienist; and a follow-up telephone call. At one year, prevalence of cessation in baseball and football teams combined was 35 percent in the intervention colleges vs. 16 percent in control colleges (P<0.01). Subjects reported that viewing graphic photographs of oral cancer-related disfigurement of the face and mouth and receiving a mouth examination with feedback relating oral tissue damage to spit tobacco use were the most helpful components of the intervention.

A third dental-based study14 was conducted at a baseball stadium on a game day during the baseball season. The study objective was to determine the relative effectiveness of two spit tobacco interventions to promote cessation among baseball players. Specifically, an oral examination by a dentist with explanation of spit tobacco-related findings, advice to quit, and photographs showing spit tobacco-related dental problems with and without brief counseling by a dental hygienist on how to quit were tested to determine their effectiveness to help 97 major league baseball athletes stop their spit tobacco use. Group assignment to either the extended or minimum intervention group was determined by alternating among the teams according to the order in which they played their first series in the San Francisco Bay Area. Of these athletes, 54 received follow-up assessments at the ballpark about three months after the intervention (28 of these spit tobacco users were in the extended intervention group and 26 in the minimum intervention group). At follow-up, prevalence of cessation was 19 percent in the extended intervention group and 0 percent in the minimum intervention group (P < 0.001), suggesting the importance of the counseling by the dental hygienist. However, the most important components of the intervention cited by the subjects were the photographs of spit tobacco-related dental problems and seeing changes in their own mouths.

Other reports(15,16) have shown that dental patients who use spit tobacco expect the dentist and dental hygienist to provide information on the risks of negative health effects associated with use, but only 50 percent of the time did they report receiving advice to quit.

In a survey of male college athletes, spit tobacco users were asked to indicate the three most important items out of a list of 11 that might influence them to stop using. Out of 473 users, 63 percent indicated "seeing changes in my teeth and gums due to spit tobacco use" and 61 percent indicated "a dentist advising me not to use."(17) In a survey of male dental patients, approximately 40 to 67 percent of the spit tobacco users reported interest in cessation assistance from the dentist, and among subjects who received a dental-based intervention, 71 percent indicated that the advice received from either the dentist or the dental hygienist significantly influenced their serious consideration of quitting.(12)

The fact that in this pilot study 35 percent (N=33) of the spit tobacco users set a quit date and only 6 percent (N=6) quit indicates a need for more intensive problem-solving and supportive treatment to be available for users. Although many athletes report quitting their tobacco habit abruptly using the "cold turkey" method, Many users have a hard time quitting because of a combination of physiological addiction to nicotine, a psychological dependence on spit tobacco, and a behavioral component that links their tobacco use with specific activities. Moreover, for baseball athletes, there is a unique environmental component that supports spit tobacco use as the social norm; and this provides a special challenge for cessation. An effective cessation program addresses all four of these dimensions. Currently, at the mandate of the Players Association, Major League Baseball plans to include an oral cancer screening exam as part of the annual health exam for players at the beginning of spring training. Moreover, NSTEP is consulting with Major League Baseball to facilitate the establishment of an infrastructure that involves not only the athletic trainers and a dental professional, but also team physicians and the Employee Assistance Program staff to provide different levels of ongoing spit tobacco cessation services for players.

In this pilot study, 39 percent (N=37) of spit tobacco users reported "being bored while waiting around," (e.g., on the field, in the dugout, or in the airport) as a high-risk situation for triggering use. In developing a quit plan with a spit tobacco user, it is important to have him identify such events or internal states that might cause him to use, and then to help him decide what he is going to do instead in the future to cope with these situations.

The majority of spit tobacco users in this pilot study reported daily use. Compared to social users, these daily users tended to be users of longer duration, to use snuff more exclusively, to use it more frequently and with more intensity (as measured by the number of minutes they kept their dip in their mouth), and to have a higher prevalence of oral lesions associated with their tobacco use. This is of concern since long-term, frequent, intense use of spit tobacco, particularly snuff, has been strongly associated with oral cancer in many studies.(18) Also, because of their nicotine dependence, daily users most likely will require use of nicotine replacement therapy to mitigate withdrawal symptoms. In addition, such plans should present basic information about the nature and time course of withdrawal, the addictive nature of spit tobacco, and the fact that even a single dip increases the likelihood of full relapse.(19)

Findings from this pilot study suggest that dental-based spit tobacco interventions can have a significant impact. Dental professionals are in an excellent position to advise and assist users to quit, and users appreciate the help. It is important to remember that quitting tobacco is not a process that takes place all at once. Cessation appears to occur along a continuum of change(20,21) in which an individual moves from a precontemplation stage where he has no thought of quitting, to a contemplation stage where he thinks he should quit someday but not now. Eventually he arrives at the readiness stage, where he has a sincere desire to quit and needs encouragement and support. Next comes the action stage, where he has made a commitment to stop using permanently, has selected a quit date, has terminated his tobacco use on that day, and is using a cessation plan to stay abstinent. In the maintenance stage, he has been tobacco-free for six months and is learning and practicing new ways of coping. Sometimes there is a relapse stage, when tobacco behaviors have resumed and may even reach higher levels than before. Many spit tobacco users try two or three times to quit before they finally succeed. During all stages, the most important thing is to remain supportive and nonjudgmental, to watch for and reinforce any signs of quit readiness, and then to provide ongoing motivation to help the user create and maintain a positive, self-confident attitude about his cessation efforts. Even when advised to quit by a dental professional, many spit tobacco users will not be ready to quit. However, it is important for dental professionals not to become discouraged, as this pilot study has shown that their advice can move users closer to the readiness stage.

Conclusion

Clearly, dental professionals can have an important role in helping young people in California to overcome this rapidly growing addiction. It is hoped that dentists and dental hygienists will incorporate the key components of the intervention described here into their clinical practice. Additionally, local dental and dental hygiene societies may wish to provide volunteers to work with college athletic trainers to provide oral exams and brief spit tobacco cessation counseling to athletes in local colleges during their mandated annual health screenings prior to their athletic seasons.

Acknowledgments

We gratefully acknowledge the support of the management, athletes, and coaches of the San Francisco Giants and the Anaheim Angels baseball organizations, and their respective team dentists, Dr. Charles Pascal and Dr. Rick Grey. Special thanks to Al Rosen, former president and general manager of the San Francisco Giants for his early leadership and concern. We also wish to acknowledge the invaluable efforts of Dr. Rick Lawson, the team dentist for the Seattle Mariners; Dr. Susan Peterson Mansfield, Leslie Finta, and Kirsten Jarvi, study dental hygienist-spit tobacco cessation counselors; T.J. Langer and Gwen Greene, dental recorders; Jana Murray, RN, and Pat Lee, RN, field coordinators; Joanna Hill, administrative assistant for the study; Dr. Herb Severson and Dr. Dorothy Hatsukami for expert spit tobacco cessation advice; and Joe Garagiola for ongoing support and encouragement. This study was supported in part by Oral Health America.

Authors

Margaret M. Walsh, EdD, is a professor of dental public health and hygiene at the University of California at San Francisco School of Dentistry.
John C. Greene, DMD, MPH, is a professor and dean emeritus of the UCSF School of Dentistry.
James A. Ellison, DDS, MPH, is an assistant clinical professor of dental public health and hygiene at UCSF School of Dentistry.
Mark A. Letendre, ATC, is the head certified athletic trainer for the San Francisco Giants baseball team.
Ned Bergert, ATC, is the head certified athletic trainer for the Anaheim Angels baseball team.

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To request a printed copy of this article, please contact/Margaret M. Walsh, MS, EdD, Department of Dental Public Health and Hygiene, UCSF School of Dentistry, 707 Parnassus Ave., Room D-1023, San Francisco, CA 94143-0754