Utilization of a Telephone Quitline by Smokeless Tobacco Users Lowell C. Dale, MD Associate Professor of Medicine College of Medicine, Mayo Clinic Medical Director, Mayo Clinic Tobacco Quitline Rochester, MN

Prevalence (2004) 7.2 million Americans used ST 7.2 million Americans used ST 4.9% of young adults (18-25 yo) past month use 4.9% of young adults (18-25 yo) past month use 6.2% of Males 6.2% of Males 0.5% of Females 0.5% of Females Results from the 2004 National Survey on Drug Use and Health: National Findings

Prevalence ST use is higher in rural areas than in urban areas ST use is higher in rural areas than in urban areas 8.0% Rural counties 8.0% Rural counties 1.7% Large metropolitan areas 1.7% Large metropolitan areas Differs by geographic area Differs by geographic area 4.1% South (highest) 4.1% South (highest) 1.5% Northeast (lowest) 1.5% Northeast (lowest) 2.2 % College graduates 3.7% High school completer/non-completers 2.2 % College graduates 3.7% High school completer/non-completers 2004 National Survey on Drug Use and Health

Health Effects: Cancers - U.S. Data Location OR (95% CI) Location OR (95% CI) Cancer, Mouth and Gum 11.2 ( ) A Cancer, Mouth and Gum 11.2 ( ) A Gum & Buccal Mucosa 4.2 ( ) B Gum & Buccal Mucosa 4.2 ( ) B Larynx 7.3 ( ) A Larynx 7.3 ( ) A Salivary gland 5.3 ( ) A Salivary gland 5.3 ( ) A Kidney cancer 4.0 ( ) C Kidney cancer 4.0 ( ) C Pancreatic cancer 3.5 ( ) D Pancreatic cancer 3.5 ( ) D A - Stockwell HG, et al. Head Neck Surg Nov-Dec;9(2): B - Winn DM, et al. N Engl J Med Mar 26;304(13): C - Goodman MT, et al. Am J Epidemiol Dec;124(6): D - Alguacil J, et al. Cancer Epidemiol Biomarkers Prev Jan;13(1):55-8.

Background Intervention programs—including telephone quitlines—have focused primarily on cigarette smokers. We describe Mayo Clinic Tobacco Quitline’s experience with a subpopulation of smokeless tobacco users who called for assistance in stopping their Smokeless Tobacco (ST) use.

Mayo Clinic Tobacco Quitline (MCTQ) Established 1998 by Mayo Clinic NDC Established 1998 by Mayo Clinic NDC Moved to Mayo Health Companies (MMSI) in 2000 Moved to Mayo Health Companies (MMSI) in 2000 Protocols jointly developed with NDC Protocols jointly developed with NDC Counseling staff of MCTQ trained by NDC personnel Counseling staff of MCTQ trained by NDC personnel Clinical oversight provided by NDC Clinical oversight provided by NDC Protocols and materials specifically designed for smokeless tobacco users Protocols and materials specifically designed for smokeless tobacco users minute assessment and development of a treatment plan minute assessment and development of a treatment plan Up to four, minute proactive follow-up calls timed around quit date and first 3 months after initial assessment Up to four, minute proactive follow-up calls timed around quit date and first 3 months after initial assessment

Methods: Subject Selection 4586 callers who enrolled in MCTQ intervention program 1/1/06-11/30/06 Only their first enrollment (if more than one) Only their first enrollment (if more than one) Seven-month outcome data was collected by MCTQ (vs. an external evaluator) Seven-month outcome data was collected by MCTQ (vs. an external evaluator) Were eligible for the seven-month outcome call Were eligible for the seven-month outcome call Reported only use of smokeless tobacco = 173 Reported only use of smokeless tobacco = 173 Males reported smoking cigarettes exclusively Males reported smoking cigarettes exclusively = 1774

Methods Telephone outcome call at 7 months after initial contact, by trained caller (not counselor) from the MCTQ Telephone outcome call at 7 months after initial contact, by trained caller (not counselor) from the MCTQ Abstinence outcome measure: self-reported, 30-day all-tobacco abstinence at seven months Abstinence outcome measure: self-reported, 30-day all-tobacco abstinence at seven months All those who could not be reached after several attempts were considered using tobacco (intention-to-treat) All those who could not be reached after several attempts were considered using tobacco (intention-to-treat) Demographic characteristics as predictors of abstinence were each assessed uni-variately using logistic regression. Age and cans/week were treated as continuous variables, all others treated as categorical variables Demographic characteristics as predictors of abstinence were each assessed uni-variately using logistic regression. Age and cans/week were treated as continuous variables, all others treated as categorical variables

Baseline Characteristics (1) Characteristic Smokeless (N=173) Cigarettes (N=1774) P-value Age: mean ± SD 40.5 ± ± Age:<.001 ≤ 35 ≤ 3532%32% %36% ≥ 51 ≥ 5115%32% Sex Male 98%100% Race<.001 Caucasian Caucasian98%88% Other Other2%12%

Baseline Characteristics (2) Characteristic Smokeless (N=173) Cigarettes (N=1774) P-value Education<.001 ≤ High school ≤ High school34%46% Some college Some college25%28% ≥College degree ≥College degree42%25% Income<.001 <$50,000 <$50,00038%59% 50, ,00046%30% >100,000 >100,00017%11% State client 52%73%<.001

Baseline Characteristics (3) Characteristic Smokeless (N=173) Cigarettes (N=1774) P-value Cans/week 4.1 ± 3.4 ≤ 3 ≤ 352% % ≥ 8 ≥ 86% Cigarettes/day 22.3 ± % % >40 >4013%

Utilization and Outcomes Smokeless (N=173) Cigarettes (N=1774) P-value* Number of follow-up calls 0.19 Mean ± SD 2.6 ± ± 1.8 Median (min, max) 3 (0,6) 2 (0,11) Outcome<.001 Abstinent50%31% Using ST/smoking 50%69% *p-values calculated using one-way ANOVA for continuous variables, chi-square for categorical

Predictors of Abstinence Smokeless Tobacco Users (N=173) CharacteristicP-value Cans/week ≤3 (57%) ≤3 (57%) 4-7 (45%) 4-7 (45%) ≥ 8 (20%) ≥ 8 (20%)0.02 Age.394 Sex.984 Education.510 Corporate* vs. State.196 Race.962 Income*.302 Time to 1 st Use*.644 Years of Use.737 Stop Confidence*.581 * Predicted abstinence in cigarette smokers + cpd

Summary Smokeless tobacco users were different from male cigarette smokers: Smokeless tobacco users were different from male cigarette smokers: Caucasian Caucasian Younger Younger Higher education Higher education Higher income Higher income Smokeless tobacco users, once engaged, used the Quitline services more than male smokers Smokeless tobacco users, once engaged, used the Quitline services more than male smokers Quit rates are high Quit rates are high Only amount of tobacco use predicted abstinence Only amount of tobacco use predicted abstinence

Conclusions IF we can expect tobacco abstinence rates to be as good as, if not better, than cigarette smokers when using a telephonic intervention specifically tailored to ST users IF we can expect tobacco abstinence rates to be as good as, if not better, than cigarette smokers when using a telephonic intervention specifically tailored to ST users THEN smokeless tobacco users should be targeted by Quitline promotions, especially in those states where the prevalence of smokeless tobacco use is high THEN smokeless tobacco users should be targeted by Quitline promotions, especially in those states where the prevalence of smokeless tobacco use is high AND treated appropriately AND treated appropriately

Authors Lowell C. Dale, MD 1,2 Lowell C. Dale, MD 1,2 Barbara Kreinbring, RN 1,2 Barbara Kreinbring, RN 1,2 Darrell Schroeder, MS 3 Darrell Schroeder, MS 3 Nathaniel Warner 3 Nathaniel Warner 3 Christopher Kasper 2 Christopher Kasper 2 1 Mayo Clinic Tobacco Quitline 2 Mayo Clinic Health Solutions 3 Division of Biostatics, Mayo Clinic