2 Public health need and practice
Many people in England of South Asian origin use a number of different types of smokeless tobacco products. Typically, these products also tend to contain other unhealthy ingredients such as areca nuts, slaked lime, flavourings and sweeteners.
The products are associated with a number of health problems including:
mouth and oropharyngeal cancer
problems in pregnancy and following childbirth (including fetal anaemia, placental pathology, stillbirth, pre-term birth, and low birthweight)
late diagnosis of dental problems (because the smokeless tobacco product helps mask the pain).
(Boffetta and Straif 2009; England et al. 2010; Gupta and Subramoney 2004; Pau et al. 2003; Quandt et al. 2005; West et al. 2004.)
There has been a steady increase in oral cancer rates in the UK since 1989 (Cancer Research UK 2010). Exactly how smokeless tobacco is linked to this increase is unknown. However, South Asian women (some of the main users of these products in the UK) are 3.7 times more likely to have oral cancer and 2.1 times more likely to have pharyngeal cancer compared with other women. This is the case, even after controlling for the effect of socioeconomic deprivation (Moles et al. 2008).
Areca nut, which is often mixed in with South Asian varieties of smokeless tobacco, is also likely to be linked to the prevalence of oral cancer among this group. Areca is a mildly euphoric stimulant. It is addictive and carcinogenic in its own right – and is widely used among South Asian groups (Auluck et al. 2009; Warnakulasuriya 2002).
Survey results (Moles et al. 2008; Prabhu et al. 2001; The NHS Information Centre 2006) suggest that the following South Asian subgroups are more likely to use smokeless tobacco:
people of Bangladeshi origin
those in older age groups
those from lower socioeconomic groups.
First generation South Asian migrants, in particular, those who are less integrated within the wider community, may also be more predisposed to using these products (Prabhu et al. 2001). In addition, South Asian users of these products may be less likely to visit the dentist on a regular basis (Pearson et al 1999).
Smokeless tobacco products are readily available in shops in areas of England where there are large South Asian communities. Around 85% of the products are sold without any regulatory health warning. Generally, they are cheap compared to cigarettes (Longman et al. 2010).
Estimates vary on the prevalence of smokeless tobacco use among 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, in some localities the prevalence may be higher. For example, another study, based on saliva analysis and questionnaires, reported that 49% of adult Bangladeshi women in Tower Hamlets used these products (Croucher et al. 2002).
One report suggests that smokeless tobacco use fell among the Bangladeshi community between 1999 and 2004 (The NHS Information Centre 2006). However, other sources appear to indicate a rise in use.
First, the number of outlets selling such products appears to be growing (Croucher et al. 2009). Second, over the last 11 years there has been a rise in legal imports of smokeless tobacco, even when the calculation is derived from the balance of imports over exports (HM Revenue & Customs 2011). Third, a recent rise in illegal imports has also been reported (HM Revenue & Customs and UK Border Agency 2008). Finally, there are also claims that the packaging of these products appears to be targeted at younger people (Panesar et al. 2008).
There is no information on current NHS smokeless tobacco cessation initiatives. A 2003 review listed 17 local services in England that claimed to focus on smokeless tobacco – and many South Asians were using such services (Crosier and McNeill 2003). Within mainstream NHS services there may be a general lack of awareness of the problem – and a lack of incentives within the system to address smokeless tobacco.