Spit Tobacco Intervention for High School Athletes

OVERVIEW

The Spit Tobacco Intervention (STI) is a behavioral intervention program designed to target male high school athletes. The program’s goal is to prevent the initiation of spit, or chewing tobacco, use among a high risk population and to encourage those already using to quit. STI makes use of a team-based, peer-led approach to make student athletes aware of the negative consequences associated with chewing tobacco. The intervention also incorporates a dental component which includes oral screenings of all team members. Overall, the Spit Tobacco Intervention was found to be successful in promoting spit tobacco (ST) cessation among current users but had no effect preventing initiation of nonusers.

DESCRIPTION OF PROGRAM

Target population: Male high school athletes at high risk for chewing tobacco use

Male high school athletes are considered a high-risk group for chewing tobacco use. The Spit Tobacco Intervention was therefore designed to specifically target male, high school baseball players. The goals of the intervention are twofold: to reduce or stop spit tobacco use among current users and to prevent the initiation of use among nonusers. The Spit Tobacco Intervention consists of two primary components which include a peer-led team meeting and a dental screening. The peer-led component is designed to provide students with information on the health effects of spit tobacco so that they are able to make an informed decision regarding ST use.

During the peer-led component, baseball team members meet at school for a single, 50-60 minute educational session. Peer leaders explain to students that they have been asked by the students’ coach to present information on the negative consequences of ST use.  Peer leaders first present a video presentation entitled “A Dangerous Game” which is followed by a brief group discussion. Following the video clip, students watch a slide presentation that portrays the harmful effects of ST use. Slides may include information and graphics on ST-related mortalities, ST ingredients, and nicotine addiction, in addition to facial and oral health effects. At this time, students are informed that their coach has arranged for dentists to meet with interested students and offer tips for quitting. Finally, students are organized into small groups to discuss three tobacco advertisements that specifically target young male athletes. All discussions are led by the trained peer leaders. Following the group discussions, students are provided with anti-spit tobacco t-shirts. At least two peer leaders per school were recruited to participate in the study. All peer leaders attended a two-hour training session prior to program implementation.

The dental component of the intervention consists of an oral cancer screening that takes place at the school. The screening is conducted by local dentists and dental hygienists. During the screening, students are encouraged to stop ST use or not to initiate use. Students are also provided with a guide and various methods to help quit. Fifteen-minute cessation counseling is available to small groups of interested students. The dental screenings are meant to motivate behavior change through personal feedback and support. Students receive a follow-up phone call to answer any remaining questions, and further encourage the quitting process. Dentists and dental hygienists are recruited and then trained in the study protocol during one-day training. Teams of one dentist and two hygienists are assigned to schools in their community.

EVALUATION(S) OF PROGRAM

Evaluated population: Male high school baseball players in rural California public schools. In total, 1,084 student athletes were included in the evaluation. Based on their baseline assessments, students were classified as ST users or nonusers (never, triers, or former users). The intervention group reported 141 users and 375 nonusers. In the control group, those numbers were 166 and 402, respectively.

Approach: All rural California public high schools with baseball teams and a prevalence of ST use were considered eligible for the evaluation. Of the 222 rural public high schools in California, 176 were randomly selected to participate in the study. Although 143 agreed to participate, 99 schools were deemed ineligible based on study criteria, primarily because ST use was below 20 percent. A total of 44 high schools ultimately qualified and agreed to participate in the evaluation. Schools were stratified by number and size of baseball teams and ST use among team members. Within strata, schools were then randomly assigned to either an intervention (n=22) or no-treatment control group (n=22). Although eligibility was determined at the school-level, consent was required of the schools, parents and student athletes in order to participate.

An initial team meeting took place at each school where students were introduced to the study, asked to complete self-report questionnaires, and provided a saliva sample. Students were evaluated again one month after the intervention using mail-in questionnaires. One year after the intervention, study personnel administered questionnaires at the students’ schools and collected saliva samples. Although students were told that saliva samples would be analyzed, samples were collected primarily to promote accuracy of self-reported measures of ST use.

Baseline measures included frequency and characteristics of ST use; predictors of ST use cessation (e.g., history of ST use & alcohol/cigarette use); predictors of ST initiation (e.g. intention to use and perceived use among peers); and demographic characteristics. At each follow-up assessment, measures included ST use; actions taken to quit; discomfort caused by quitting attempts; perceived effects on athletic performance; intention to use in the future; current cigarette use; and an assessment of the evaluation. ST cessation was defined as students who used at baseline but reported no use at both follow-up periods. ST initiation was defined as students who did not use at baseline but who reported ST use at either follow-up period.

Results: The Spit Tobacco Intervention was found to encourage cessation among ST users. In fact, the ST cessation rate was 27 percent among students in the intervention in comparison to only 14 percent in control high schools. The strongest predictor of quitting was being a smoker. Among all ST users, students who used ST weekly or monthly were much more likely to quit than daily users.  Smoking status was also found to significantly modify the intervention effect (p=.03), indicating that the Spit Tobacco Intervention was only successful among nonsmokers. Fifty-three percent of intervention subjects and fifty-four percent of control subjects reported seriously trying to quit ST use during the past year. Among those who attempted quitting, intervention students were much more likely than control students to report using two of the recommended program methods: cutting out use at favorite times (OR=2.00) or switching to a lower nicotine brand (OR=1.5). 

The Spit Tobacco Intervention was not found to have an impact on ST initiation of nonusers. Approximately 11 percent of control students and 12 percent of intervention students reported initiating use during the evaluation and this difference was not statistically significant. History of ST use, intention to use in the future, perceived use among peers and current smoking status were all found to significantly predict ST initiation among all participants.

Although the study did make use of saliva samples to help ensure reliable estimates of ST use, one limitation of the study is the use of self-report measures. Self-report measures may be subject to social desirability bias and therefore lead to an underestimation of actual prevalence rates.

SOURCES FOR MORE INFORMATION

References

Walsh, M.M., Hilton, J.F., Ellison, J.A., Gee, L., Chesney, M.A., Tomar, S.L., & Ernster, V.L. (2003). Spit (smokeless) Tobacco Intervention for high school athletes: Results after 1 year. Journal of Addictive Behaviors, 28, 1095-1113.

Program categorized in this guide according to the following:

Evaluated participant ages: High school students

Program age ranges in the Guide: 12-14, 15-21

Program components: clinic-based, provider-based, or miscellaneous; counseling/therapy; school-based

Measured outcomes: social and emotional health and development; behavioral problems

Program information last updated 9/28/06.

© Child Trends 2003