Patient Name: ___________________________
Date: ___________________________
Nurse/Provider: ___________________________
1. Why Quitting Smokeless Tobacco Matters
Smokeless tobacco (chew, dip, snuff, snus) contains high levels of nicotine and many cancer-causing chemicals. Quitting reduces your risk of:
Mouth, tongue, throat, esophagus, and pancreatic cancers
Gum disease and tooth loss
Receding gums
Heart disease and high blood pressure
Stomach and digestive problems
Nicotine addiction
Your body begins repairing itself within days of quitting.
2. What to Expect After You Quit
You may feel:
Cravings or urges
Irritability, anxiety, or restlessness
Trouble concentrating
Increased appetite
Mild headaches
Sore mouth as tissues heal
Changes in taste or saliva
These are temporary and usually improve within 2–4 weeks.
3. Tips to Help You Stay Tobacco-Free
Avoid triggers: driving long distances, work breaks, sports, stress, after meals.
Keep your mouth busy: sugar-free gum, sunflower seeds, healthy snacks.
Stay hydrated: drink plenty of water during cravings.
Break old habits: choose different routes, adjust routines, and keep hands busy.
Clean your environment: throw away cans, pouches, spit bottles, and all tobacco items.
Seek support: tell family and friends that you are quitting.
4. Replacement Options and Medications
Smokeless tobacco users often benefit from nicotine replacement therapy (NRT) because dip/chew delivers high nicotine.
Nicotine Replacement Therapy (NRT)
Nicotine gum (2 mg or 4 mg) – helpful for oral cravings
Nicotine lozenges – dissolve slowly to curb cravings
Nicotine patch – steady nicotine all day
Nicotine inhaler — optional for behavioral support
Prescription Medications
Bupropion SR (Zyban) — helps decrease cravings
Varenicline (Chantix) — reduces pleasure and urges
Medications/NRT Provided Today:
☐ None
☐ Gum (____ mg)
☐ Lozenges (____ mg)
☐ Patch (____ mg)
☐ Inhaler
☐ Varenicline
☐ Bupropion SR
Instructions: ___________________________________________
5. Warning Signs — When to Call Your Provider
Seek medical help if you experience:
Chest pain or trouble breathing
Severe depression or suicidal thoughts (bupropion/varenicline)
Signs of infection in the mouth: swelling, pus, fever
Fast or irregular heartbeat
Allergic reaction: rash, swelling, difficulty breathing
6. Follow-Up Plan
Follow-up is important for staying quit.
Next Appointment: _______________________________
Telephone: ______________________________________
7. Tools and Support
Quitline (24/7): 1-800-QUIT-NOW
Text Support: Text “QUIT” to 47848
Apps: QuitGuide, QuitNow!, SmokeFree
Website: smokefree.gov
8. Your Quit Plan
Quit Date: ________________________________________
Patient Signature: __________________ Date: _________
Provider Signature: ________________ Date: _________
Date: ___________________________
Nurse/Provider: ___________________________
1. Why Quitting Smokeless Tobacco Matters
Smokeless tobacco (chew, dip, snuff, snus) contains high levels of nicotine and many cancer-causing chemicals. Quitting reduces your risk of:
Mouth, tongue, throat, esophagus, and pancreatic cancers
Gum disease and tooth loss
Receding gums
Heart disease and high blood pressure
Stomach and digestive problems
Nicotine addiction
Your body begins repairing itself within days of quitting.
2. What to Expect After You Quit
You may feel:
Cravings or urges
Irritability, anxiety, or restlessness
Trouble concentrating
Increased appetite
Mild headaches
Sore mouth as tissues heal
Changes in taste or saliva
These are temporary and usually improve within 2–4 weeks.
3. Tips to Help You Stay Tobacco-Free
Avoid triggers: driving long distances, work breaks, sports, stress, after meals.
Keep your mouth busy: sugar-free gum, sunflower seeds, healthy snacks.
Stay hydrated: drink plenty of water during cravings.
Break old habits: choose different routes, adjust routines, and keep hands busy.
Clean your environment: throw away cans, pouches, spit bottles, and all tobacco items.
Seek support: tell family and friends that you are quitting.
4. Replacement Options and Medications
Smokeless tobacco users often benefit from nicotine replacement therapy (NRT) because dip/chew delivers high nicotine.
Nicotine Replacement Therapy (NRT)
Nicotine gum (2 mg or 4 mg) – helpful for oral cravings
Nicotine lozenges – dissolve slowly to curb cravings
Nicotine patch – steady nicotine all day
Nicotine inhaler — optional for behavioral support
Prescription Medications
Bupropion SR (Zyban) — helps decrease cravings
Varenicline (Chantix) — reduces pleasure and urges
Medications/NRT Provided Today:
☐ None
☐ Gum (____ mg)
☐ Lozenges (____ mg)
☐ Patch (____ mg)
☐ Inhaler
☐ Varenicline
☐ Bupropion SR
Instructions: ___________________________________________
5. Warning Signs — When to Call Your Provider
Seek medical help if you experience:
Chest pain or trouble breathing
Severe depression or suicidal thoughts (bupropion/varenicline)
Signs of infection in the mouth: swelling, pus, fever
Fast or irregular heartbeat
Allergic reaction: rash, swelling, difficulty breathing
6. Follow-Up Plan
Follow-up is important for staying quit.
Next Appointment: _______________________________
Telephone: ______________________________________
7. Tools and Support
Quitline (24/7): 1-800-QUIT-NOW
Text Support: Text “QUIT” to 47848
Apps: QuitGuide, QuitNow!, SmokeFree
Website: smokefree.gov
8. Your Quit Plan
Quit Date: ________________________________________
Patient Signature: __________________ Date: _________
Provider Signature: ________________ Date: _________
