Sep 28, 2006


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.


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

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.

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.

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.


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,

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.

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.



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,

KEYWORDS: Adolescents (12-17), Youth (16-24), Young
Adulthood (18-24), High School, School-Based, Clinic-Based, Gender-Specific
(Male Only), Mentoring, Education, High-Risk, Substance Use, Tobacco Use,
Rural, Athletes, Health.

Program information last updated 9/28/06.