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Spit Tobacco Intervention for High School Athletes

Ages 14-18

Rating: Level 2


The Spit Tobacco Intervention for High School Athletes subjects young males who use or are at risk of using spit-tobacco—especially baseball players—to an education program about the dangers of addiction and long-term use. The program aims to prevent or cease their spit-tobacco use.

Grounded in cognitive social learning theory, the intervention consists of two parts: a single-session, peer-led component and a dental component. The first component typically consists of a 50-minute, interactive meeting that includes a video, graphic slides of facial disfigurement associated with oral cancer and its surgical treatment, and a small group discussion of spit-tobacco advertisements aimed at young males. The dental component includes an oral exam from a dentist. In addition, a behavioral counseling session helps participants establish a quit date. The brief counseling also explains nicotine addiction and suggests coping strategies for spit-tobacco cravings either to increase positive feelings or to decrease negative emotions and other withdrawal symptoms. Moreover, counseling points out that spit-tobacco use can be a highly automatic behavior intensely learned and practiced over time, so that the user can find himself using spit-tobacco without deliberate realization or conscious desire. To address this automatic use of spit-tobacco, counselors have athletes recall their spit-tobacco use in a typical day to identify reasons for use and to target dips used automatically for initial elimination in planning a schedule to taper down spit-tobacco use and gradually reduce nicotine exposure. Program participants also receive a follow-up call from a dental hygienist to discuss a quit date.


The Spit Tobacco Intervention program has been evaluated through five randomized controlled trials. The most recent was a cluster-randomized controlled trial in which 44 randomly selected high schools in rural California were randomized within strata (prevalence of spit-tobacco use and number and size of baseball teams) to either the intervention (n=516) or control group (n=568). An eligible high school was required to have a baseball team with at least a 20 percent estimated baseline spit-tobacco use prevalence, according to the coach, and at least a 10 percent actual baseline prevalence, as determined by responses to questionnaires administered to team members before randomization. The control sample was made up of 27.7 percent seniors, 34.3 percent juniors, 28.9 percent sophomores, and 9.0 percent freshman. The intervention sample consisted of 29.1 percent seniors, 40.4 percent juniors, 17.0 percent sophomores, and 13.5 percent freshman. The prevalence of sustained spit-tobacco cessation and spit-tobacco use initiation over 1 year were assessed by self-report questionnaires and the collection of saliva specimens.


The intervention appears to be effective in promoting spit-tobacco cessation but ineffective in preventing the initiation of spit-tobacco use by nonusers. Prevalence of cessation was 27 percent in intervention high schools and 14 percent in control high schools. The intervention was most effective in promoting cessation among those who, at baseline, lacked confidence that they could quit, among freshman, and among nonsmokers. There was no significant difference between groups in the prevalence of spit-tobacco initiation.

Risk Factors


  • Poor refusal skills


  • Availability of alcohol and other drugs


  • Peer alcohol, tobacco, and/or other drug use
  • Peer rejection

Protective Factors


  • Healthy / Conventional beliefs and clear standards


  • Good relationships with peers
  • Involvement with positive peer group activities


  • SAMHSA: Model Programs


Gansky, Stuart, James A. Ellison, Catherine Kavanagh, Joan F. Hilton, and Margaret M. Walsh. 2002. “Oral Screening and Brief Spit-Tobacco Cessation Counseling: A Review and Findings.” Journal of Dental Education 66(9):1088–98.

Walsh, Margaret M., Joan F. Hilton, James A. Ellison, Lauren Gee, Margaret A. Chesney, Scott L. Tomar, and Virginia L. Ernster. 2003. “Spit (Smokeless) Tobacco Intervention for High School Athletes: Results After 1 Year.” Addictive Behaviors 28:1095–1113.


Margaret M. Walsh
Divisions of Oral Epidemiology and Dental Public Health, School of Dentistry
3333 California Street, Suite 495
San Francisco, CA 94143–1364
Phone: (415) 502-4510
Fax: (415) 502-8447