1 Recommendations

Introduction

The Public Health Interventions Advisory Committee (PHIAC) considers that the recommended approaches are cost effective.

The evidence statements underpinning the recommendations are listed in appendix C.

The recommendations in this guidance reflect the evidence identified and the discussions of PHIAC. For some approaches, there was no evidence and their absence should not be taken as a judgement on whether they are effective or cost effective.

For the research recommendations and gaps in research, see section 5 and appendix D respectively.

Background

This guidance focuses on cessation, that is, interventions that help people of South Asian origin to stop using smokeless tobacco products. While prevention activities are, strictly speaking, outside its scope, some of the interventions identified may also help stop people from taking up the habit in the first place. (For example, they may help young people who are experimenting with tobacco to give it up before they become addicted to it.)

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.

The gender, age, occupation, religious background and country of origin of users within South Asian communities living in England will vary across the country, so the approaches recommended will need to be tailored accordingly.

Smokeless tobacco

The guidance covers a variety of smokeless tobacco products used by people of South Asian origin in England. The types used vary across the country but they can be divided into 3 main categories, based on their ingredients (Stanfill et al. 2010):

  • Tobacco with or without flavourants: misri India tobacco (powdered) and qimam (kiman).

  • Tobacco with various alkaline modifiers: khaini, naswar (niswar, nass) and gul.

  • Tobacco with slaked lime as an alkaline modifier and areca nut: gutkha, zarda, mawa, manipuri and betel quid (with tobacco).

Users do not always recognise the term 'smokeless tobacco'. Sometimes they will be unaware that the products contain tobacco (although the products are legally required to carry a health warning[3]). That is why it is also necessary to refer to these products by the names used locally.

A number of the products contain areca nut, a mildly euphoric stimulant which is addictive and carcinogenic in its own right. (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.)

Specialist tobacco cessation services

In this guidance, 'Specialist tobacco cessation services' refers to evidence-based services that offer tobacco users support to help them quit (regardless of whether they smoke or use a smokeless variety). In England, services of this type are generally referred to as 'stop smoking services' or 'smoking cessation services' as they normally focus on people who smoke tobacco. However, a service might also brand itself as a generic tobacco cessation service, to emphasise a focus on more than one form of tobacco. For further details, see NICE guidance on smoking cessation services.

Brief interventions

Brief interventions involve verbal advice, discussion, negotiation or encouragement, with or without written or other support or follow-up. They can be delivered by a range of primary and community care professionals. These interventions are often opportunistic, typically taking no more than a few minutes for basic advice, up to around 20 minutes for a more extended, individually-focused discussion. They may also involve a referral for further interventions or more intensive support.

Evidence shows that a brief intervention to help people quit smoking can be effective. The way a brief intervention to help smokers is delivered depends on a number of factors, including the person's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:

  • simple opportunistic advice

  • an assessment of the person's commitment to quit

  • pharmacotherapy and/or behavioural support

  • self-help material

  • referral to more intensive support such as to an evidence-based smoking cessation service.

(See NICE guidance on brief interventions and referral for smoking cessation and smoking cessation services for more information on the general principles of tobacco cessation.)

Whose health will benefit from the recommendations?

  • Members of South Asian communities in England who use smokeless tobacco products. This includes people who are isolated from these communities, for example, because they live outside the immediate area where the community is based, or because they rarely leave their home.

  • People of South Asian origin are the focus of this guidance as they are the predominant users of smokeless tobacco products in England. However, others who use these products may also benefit from the recommendations, as health professionals, as a result, will be more aware of how to identify and help them.

Recommendation 1 Assessing local need

Who should take action?

  • Directors of public health.

  • Local authority specialists and public health commissioners responsible for local tobacco cessation activities.

  • Health and wellbeing boards.

  • Clinical commissioning groups.

  • Dental public health consultants.

  • Managers of tobacco cessation services.

What action should they take?

  • As part of the local joint strategic needs assessment (JSNA), gather information on where, when and how often smokeless tobacco cessation services are promoted and provided to local South Asian communities – and by whom. Aim to get an overview of the services on offer.

  • Consult with local voluntary and community organisations that work with, or alongside, South Asian communities to understand their specific issues and needs in relation to smokeless tobacco (see recommendation 2).

  • Collect and analyse data about the use of smokeless tobacco among local South Asian communities. For example, collect data from local South Asian voluntary and community organisations, dental health professionals and primary and secondary care services. These data should provide information on:

    • prevalence and incidence of smokeless tobacco use and detail on the people who use it (for example, their age, ethnicity, gender, language, religion, disability status and socioeconomic status)

    • people who use smokeless tobacco and do not use cessation services

    • types of smokeless tobacco used

    • perceived level of health risk associated with these products

    • circumstances in which these products are used locally

    • proportion and demographics of people who both smoke and use smokeless tobacco products.

  • Consider working with neighbouring local authorities to analyse routinely collected data from a wider geographical area on the health problems associated with smokeless tobacco among local South Asian communities. In particular, collect and analyse data on the rate of oropharyngeal cancers. Note any demographic patterns. Data could be gathered from local cancer registers, Hospital Episode Statistics, public health observatories and local cancer networks.

  • Collect any available information from tobacco cessation services on the number of South Asian people who have recently sought help to give up smoking or smokeless tobacco. Depending on the level of detail available, data should be broken down demographically (for example, by age, ethnic suborigin, gender, religion and socioeconomic status).

  • Use consistent terminology to describe the products, as specified in the Local Government Association's Niche tobacco products directory website. Note any local variation in the terminology used by retailers and consumers.

Recommendation 2 Working with local South Asian communities in areas of identified need

Who should take action?

  • Directors of public health.

  • Local voluntary and community organisations with a responsibility for tobacco cessation or that work with South Asian communities.

  • Managers of tobacco cessation services.

  • People who work with children and young people.

  • Faith leaders and others involved in faith centres.

  • Health and social care practitioners, for example, midwives, health visitors and youth workers.

  • Health and wellbeing boards.

  • Clinical commissioning groups.

  • Dental health professionals including dentists, dental hygienists and dental nurses.

  • Others with a remit for managing tobacco cessation services or with responsibility for the health and wellbeing of South Asian communities.

What action should they take?

  • Work with local South Asian communities to plan, design, coordinate, implement and publicise activities to help them stop using smokeless tobacco. Develop relationships and build trust between relevant organisations, communities and people by involving them in all aspects of planning. Take account of existing and past activities to address smokeless tobacco use and other health issues among these communities. (Also see NICE guidance on community engagement.)

  • Work with local South Asian communities to understand how to make services more accessible. For example, if smokeless tobacco cessation services are provided within existing mainstream tobacco cessation services, find out what would make it easier for South Asian people to use the service.

  • Work in partnership with existing community initiatives to raise awareness of local smokeless tobacco cessation services and how to access them. Ensure any material used to raise awareness of the services:

    • uses the names that the smokeless tobacco products are known by locally, as well as the term 'smokeless tobacco' (see recommendation 1)

    • provides information about the health risks associated with smokeless tobacco and the availability of services to help people quit

    • challenges the perceived benefits – and the relative priority that users may place on these benefits (compared with the health risks). For example, some people think smokeless tobacco is an appropriate way to ease indigestion or relieve dental pain, or helps freshen the breath

    • addresses the needs of people whose first language is not English (by providing translations)

    • addresses the needs of people who cannot read in any language (by providing material in a non-written form, for example, in pictorial, audio or video format)

    • includes information for specific South Asian subgroups (for example, older Bangladeshi women) where rates of smokeless tobacco use are known to be high

    • discusses the concept of addiction in a way that is sensitive to culture and religion (for example, it may be better to refer to users as having developed a 'habit', rather than being 'addicted')

    • does not stigmatise users of smokeless tobacco products within their own community, or in the eyes of the general community.

  • Use existing local South Asian information networks (including culturally specific TV and radio channels), and traditional sources of heath advice within South Asian communities to disseminate information on smokeless tobacco.

  • Use venues and events that members of local South Asian communities frequent to publicise, provide or consult on cessation services with them. (Examples include educational establishments and premises where prayer groups or cultural events are held.)

  • Raise awareness among those who work with children and young people about smokeless tobacco use. This includes:

    • providing teachers with information on the harm that smokeless tobacco causes and which also challenges the perceived benefits – and the priority that users may place on these perceived benefits

    • encouraging teachers to discuss with their students the reasons why people use smokeless tobacco. This could take place as part of drug education, within personal, social, health and economic (PSHE) education, or within any other relevant part of the curriculum.

Recommendation 3 Commissioning smokeless tobacco services in areas of identified need

Who should take action?

  • Directors of public health.

  • Public health commissioners and local authority specialists responsible for local tobacco cessation services.

  • Health and wellbeing boards.

  • Clinical commissioning groups.

  • Managers of tobacco cessation services.

What action should they take?

  • If local needs assessment shows that it is necessary (see recommendation 1), commission a range of services to help South Asian people stop using smokeless tobacco. Services should be in line with any existing local agreements or local enhanced service arrangements.

  • Provide services for South Asian users either within existing tobacco cessation services or, for example, as:

    • A stand-alone service tailored to local needs (see recommendation 5). This might cater for specific groups such as South Asian women, speakers of a specific language or people who use a certain type of smokeless tobacco product (the latter type of service could be named after the product, for example, it could be called a 'gutkha' cessation service).

    • Part of services offered within a range of healthcare and community settings (for example, GP or dental surgeries, community pharmacies and community centres – see recommendation 4).

  • Ensure 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. The services (and activities to promote them) should also be coordinated with, or linked to, national stop smoking initiatives and other related national initiatives (for example, dental health campaigns).

  • Ensure services are part of a wider approach to addressing the health needs facing South Asian communities. They should be planned in partnership with relevant local voluntary and community organisations and user groups, and in consultation with local South Asian communities (see recommendation 2).

  • Ensure services take into account the fact that some people who use smokeless tobacco products also smoke tobacco.

  • Ensure services take into account the needs of people:

    • from different local South Asian communities (for example, by using staff with appropriate language skills or translators, or by providing translated materials or resources in a non-written format)

    • who may be particularly concerned about confidentiality

    • who may not realise smokeless tobacco is harmful

    • who may not know help is available

    • who may find it difficult to use existing local services because of their social circumstances, gender, language, culture or lifestyle.

  • Regularly monitor and evaluate all local smokeless tobacco cessation services (and activities to promote them). Ensure they are effective and acceptable to service users. Where necessary, adjust services to meet local need more effectively. The following outcomes should be reported:

    • number of quit attempts

    • percentage of successful quit attempts at 4 weeks

    • percentage of quit attempts leading to an adverse or unintended consequence (such as someone switching to, or increasing, their use of smoked tobacco or areca nut-only products).

Recommendation 4 Providing brief advice and referral: dentists, GPs, pharmacists and other health professionals

Who should take action?

  • Primary and secondary dental care teams (for example, dentists, dental nurses and dental hygienists).

  • Primary and secondary healthcare teams (for example, GPs and nurses working in GP practices).

  • Health professionals working in the community, including community pharmacists, midwives and health visitors.

What action should they take?

  • Ask people if they use smokeless tobacco, using the names that the various products are known by locally. If necessary, show them a picture of what the products look like, using visual aids. (This may be necessary if the person does not speak English well or does not understand the terms being used.) Record the outcome in the patient notes.

  • If someone uses smokeless tobacco, ensure they are aware of the health risks (for example, the risk of cardiovascular disease, oropharyngeal cancers and periodontal disease). Use a brief intervention to advise them to stop.

  • In addition to delivering a brief intervention, refer people who want to quit to local specialist tobacco cessation services (see NICE guidance on smoking cessation services). This includes services specifically for South Asian groups, where they are available.

  • Record the response to any attempts to encourage or help them to stop using smokeless tobacco in the patient notes (as well as recording whether they smoke).

See also NICE guidance on brief interventions and referral for smoking cessation and smoking cessation services for more information.

Recommendation 5 Specialist tobacco cessation services in areas of identified need

Who should take action?

Providers of tobacco cessation services. This may include those working in general practice, dental practices and pharmacies.

What action should they take?

As part of a comprehensive specialist tobacco cessation service ensure:

  • Staff provide advice to people who use smokeless tobacco (or recommend that they get advice to help them quit).

  • Staff know the local names to use when referring to smokeless tobacco products (see recommendation 1).

  • Staff can advise people on how to cope with the potential adverse effects of quitting smokeless tobacco. This includes, for example, knowing how to refer people for help to cope with oral pain, as well as general support to cope with withdrawal symptoms.

  • Staff offer people who use smokeless tobacco help to prevent a relapse following a quit attempt. If possible, they should also validate the quit attempt by using a cotinine test (saliva examination) and monitor for any possible increase in tobacco smoking or use of areca nut.

  • Services reach people who may not realise smokeless tobacco is harmful, or who may not know that help is available should they need it.

  • Services reach people who may find it difficult to use existing local services because of their social circumstances, gender, language, culture or lifestyle. For example, a home outreach service might be considered for older people or women from South Asian groups.

  • Staff check whether smokeless tobacco users also smoke tobacco and, if that is the case, provide help to quit them both.

See also NICE guidance on brief interventions and referral for smoking cessation and smoking cessation services for more information.

Recommendation 6 Training for practitioners in areas of identified need

Who should take action?

  • Commissioners of health and dental services.

  • Commissioners of health education and training services.

What action should they take?

  • Ensure training for health, dental health and allied professionals (for example, community pharmacists) covers:

    • the fact that smokeless tobacco may be used locally – and the need to keep abreast of statistics on local prevalence

    • the reasons why, and how, members of the South Asian community use smokeless tobacco (including the cultural context for its use)

    • the health risks associated with smokeless tobacco

    • the fact that some people of South Asian origin may be less used to a 'preventive' approach to health than the general population

    • the local names used for smokeless tobacco products, while emphasising the need to use the term 'smokeless tobacco' as well when talking to users about them (see recommendation 1).

  • Training should also ensure practitioners:

    • can recognise the signs of smokeless tobacco use

    • know how to ask someone, in a sensitive and culturally aware manner, if they use smokeless tobacco

    • can provide information in a culturally sensitive way on the harm smokeless tobacco causes. (This includes being able to challenge any perceived benefits – and the relative priority that users may place on these benefits)

    • can deliver a brief intervention and refer people to tobacco cessation services if they want to quit.



[3] Smokeless tobacco products are required to carry the warning: 'This tobacco product can damage your health and is addictive' on the most visible surface of the packet. Refer to the Local Government Association's Niche Tobacco Products Directory website for further details.

  • National Institute for Health and Care Excellence (NICE)