The National Institute for Health and Care Excellence (NICE) today (Wednesday 26 September) publishes final guidance on providing support for people in South Asian communities on stopping the use of smokeless tobacco products, such as Paan, Gutka, Shupari, and Betel Quid. Contrary to perceptions that these types of products are healthy or beneficial, they are in fact associated with serious health problems such as oral cancer, serious dental problems, heart attack and stroke, and problems in pregnancy.

The NICE public health guidance makes recommendations for tackling the use of these smokeless tobacco products which are typically available in South Asian communities in England. It's thought that using these products is one of the main reasons why South Asian women are nearly four times more likely to develop oral cancers than women from other ethnic groups in England. Smokeless tobacco use is often highest among older women of South Asian descent, but in some parts of the UK, a high percentage of young South Asians are also reported as using these products.

The NICE guidance recommendations include:

• In areas of identified need, commissioning a range of services to help South Asian people stop using smokeless tobacco, ensuring that local smokeless tobacco cessation services are coordinated and integrated with other tobacco control, prevention and cessation activities, as part of a comprehensive local tobacco control strategy
• Ensuring that any materials on smokeless tobacco cessation: refer to the products using the names people use locally; provide information about the risks associated with smokeless tobacco and the availability of services to help people quit; and challenge the perceived benefits of smokeless tobacco (for example, that it is an appropriate way to ease indigestion or dental pain, or that it helps freshen the breath)
• Ensuring that training for health, dental health and allied professionals (for example, community pharmacists) covers: the health risks associated with smokeless tobacco; the fact that smokeless tobacco may be used locally; and the local names used for smokeless tobacco products. Training should enable practitioners to recognise the signs of smokeless tobacco use and ensure that they can deliver a brief intervention and refer people to tobacco cessation services if they want to quit
• Advising that dentists, GPs, pharmacists, dental and GP practice nurses, midwives, health visitors and other health professionals should provide brief advice and referral, including recording the response to any attempts to encourage or help people to stop using smokeless tobacco in their patient notes (as well as recording whether they smoke).

Professor Mike Kelly, Director of the NICE Centre for Public Health Excellence, said: “This guidance is an important opportunity to highlight the range of serious health risks associated with smokeless tobacco products, such as paan or gutkha, which are used by some people of South Asian origin. Often the people using these products aren't aware that they contain tobacco, nor that they could be at greater risk of oral cancers or cardiovascular disease.

“There's also low awareness of the health problems caused by these smokeless tobacco products within mainstream NHS services. We hope that this guidance will inform health professionals of the risks posed by these products, so they can take action by asking patients of South Asian origin if they use smokeless tobacco, making sure they are aware of the health risks, and where appropriate referring people for support to help them stop using these products.”

Bilkis Hussain, Smokeless Tobacco Adviser at the Leicestershire Partnership Trust and expert advisor to the NICE committee which produced the guidance, said: ”I'm based at a dental practice, and my focus is advising people from South Asian communities on the health risks of using smokeless tobacco products like paan. This NICE guidance will therefore not only be very helpful in setting out how different health professionals can effectively tackle smokeless tobacco use in relevant populations in their care, but the guidance is also really important in raising wider awareness of this health issue and dispelling myths about smokeless tobacco being seen as beneficial. I hope that all health care professionals who work with South Asian communities will put the guidance recommendations into practice, to help improve the health of this population.”

The guidance is available from 26 September.

ENDS

Notes to Editors

About the guidance, ‘Smokeless tobacco cessation: South Asian communities'

1. The guidance is available from 26 September.

2. The phrase 'people of South Asian origin' is used in this guidance to mean people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka.

3. The term 'smokeless tobacco' is used in this guidance to refer to any type of product containing tobacco that is placed in the mouth or nose and not burned and which is typically used in England by people of South Asian origin. It does not include products that are sucked, like ‘snus' or similar oral snuff products, as defined in the European Union's "Tobacco Product Directive". Under UK law it is an offence to supply tobacco for oral use unless it is intended to be smoked or chewed. While product names like Paan, Gutka, Shupari, and Betel Quid are common, there are many naming variations, and also different products are used in different parts of the country. In addition, the term ‘smokeless tobacco' is not always recognised by users. Sometimes they will be unaware that the products they use contain tobacco.

4. Smokeless tobacco products typically may contain other unhealthy ingredients such as areca nuts (a mildly euphoric stimulant, known to be addictive and carcinogenic - linked to oral cancers) and slaked lime (calcium hydroxide) - used to make cement, and treat acidic water), as well as flavourings and sweeteners. (Any chewable products that do not contain tobacco are the responsibility of the Food Standards Agency. The Agency is currently working with UK Asian communities to provide guidance on how to minimise the risk from consuming products containing areca nut.)

5. Estimates vary on how much smokeless tobacco products are used by South Asian communities. The NHS Information Centre (2006) confirmed that Bangladeshis were the biggest users among this community in 2004, with 9% of men and 16% of women saying that they used these products. However, these figures may be an underestimate.

6. South Asian women were 3.7 times more likely to have oral cancer and 2.1 times more likely to have pharyngeal cancer compared with other women [Moles et al. 2008].

7. Research indicates that around 28% of Bangladeshi adolescents in one study in East London use smokeless tobacco products [Prabhu et al. 2001].

8. Around 85% of the smokeless tobacco products used by people of South Asian origin are sold without a regulatory health warning on the packet. UK law says the products should carry a health warning: 'This tobacco product can damage your health and is addictive' on the most visible surface of the packet. Many are sold without a warning that they contain tobacco [Longman et al 2010].

9. The recommendations should be implemented as part of other activities and services to address the general health needs of South Asian communities. The recommendations have been made within the context of local tobacco control strategies, including the provision of local services and initiatives to prevent the uptake of tobacco and help smokers and other tobacco users to quit. Wider tobacco control measures, for example, legislation, taxation, advertising regulation and the use of health warnings on products, are not covered.

10. NICE public health guidance applies to England and is not mandatory.

About NICE

11. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

12. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

13. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
• Commissioning Outcomes Framework - NICE develops the potential indicators for the COF, the scheme starting in 2013, which will help measure the health outcomes and quality of care commissioned by Clinical Commissioning Groups.

14. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates high quality guidance and evidence-based information to help professionals deliver the best patient care through NHS Evidence.