Subjects who were assigned to the ST reduction group were also given information on the harms associated with tobacco use; the reduction in exposure to toxic substances with reduction in use (as confirmed by prior studies); the uncertainty of whether reduction in level of use will result in significant reduction selleck screening library in harm, although some harms are presumed to be dose-related; and the importance of making cessation the ultimate goal to achieve true reduction in harm. On the Week 0 visit, subjects were provided with their choice of either 4 mg nicotine lozenge (Commit(r)) or brand switching to help them reduce their ST consumption. Nicotine lozenge was offered because in our pilot ST reduction study, there was a trend toward more subjects achieving a ��75% reduction in dips per day and a higher 7-day self-reported tobacco abstinence rate (14% vs.

6.7%) compared with the no nicotine lozenge group (Ebbert et al., 2010). The lozenge was also offered because lozenge use sustains some of the sensory aspects of ST use. Subjects choosing the lozenge were instructed on appropriate use of the lozenge as described in the product insert. Subjects were advised to substitute a lozenge for every other dip at the 50% reduction for the first 2 weeks and use lozenges in a 3:1 ratio to meet the 75% reduction goal. If subjects assigned to the 4 mg lozenge experienced symptoms of nicotine toxicity, they were downtitrated to the 2 mg product. Subjects choosing brand switching switched to Skoal Long Cut Straight or Long Cut Wintergreen to meet the ~25% to 50% nicotine reduction for the first 2 weeks.

These ST products have a free nicotine content of 4.99 and 4.41 mg/g, respectively. The usual brand products popular among subjects in our study included Kodiak Wintergreen, Grizzly Long Cut Wintergreen, and Copenhagen Long Cut Regular, which have free nicotine content that ranges from 5.67 mg/g to 7.14 mg/g (Richter, Hodge, Stanfill, Zhang, & Watson, 2008 ). Subjects then switched to Skoal Bandits Wintergreen or Skoal Bandits Straight for the 4 weeks of ��75% nicotine reduction Cilengitide (free nicotine content 0.39 and 0.03 mg/g, respectively; Centers for Disease Control and Prevention, 1999 ; Richter et al., 2008). ST users who already used Skoal as their usual brand were encouraged to be in the nicotine lozenge reduction arm. A targeted quit date after the 4 weeks of ��75% reduction was established. Subjects, however, could spontaneously express an interest in quitting prior to Week 6. Strategies for reduction were discussed and concerns or obstacles about reduction were elicited from the subject. A structured treatment plan for reduction was provided, including ways to monitor use. At 6 weeks, on their quit date, subjects received a phone call for behavioral counseling.