The Public Health Interventions Advisory Committee (PHIAC) took account of a number of factors and issues when developing the recommendations.
3.1 PHIAC noted that there is limited evidence on the prevalence and severity of smokeless tobacco use among South Asians in England. PHIAC was also aware that usage patterns vary greatly from area to area, both demographically and in terms of the products themselves (although in many areas, use is often high among older Bangladeshi women). The Committee noted that these factors will present a challenge when planning services.
3.2 PHIAC noted that smokeless tobacco use is an emerging public health issue. However, there is a lack of awareness of the problem, both among the public and professionals. The Committee noted that it would take a concerted effort to increase the provision and consistency of smokeless tobacco cessation services across England to the optimum level.
3.3 PHIAC noted that cessation interventions should fit well into an holistic model of care for people for whom the health hazards of using smokeless tobacco might be a minor concern compared with the other health and social problems they may face.
3.4 PHIAC noted the importance of using existing NICE guidance on behaviour change: the principles for effective interventions, identifying and supporting people most at risk of dying prematurely and community engagement when developing interventions to help people from South Asian communities to stop using smokeless tobacco.
3.5 Members of PHIAC were aware that smokeless tobacco use may be high among some groups of young South Asians, although there is a lack of recent, high quality research on this. As with smoking, they also recognised that children and young people may experiment with smokeless tobacco before becoming regular users. As a result, although the guidance focuses on cessation, in practice the boundary between prevention and cessation work may be blurred.
3.6 Apart from being physically addictive, smokeless tobacco products are, to a large extent, tied into the culture and traditions of some South Asian communities. Offering someone such a product can be a polite social ritual. When the tobacco mixture contains areca nut, its use can also have religious significance (areca nut is considered sacred in a number of cultures). In some cases, smokeless tobacco is part of someone's cultural identity and the upheaval of migration can create a particularly strong attachment to it.
3.7 PHIAC noted that some people who have migrated to the UK may feel uneasy about certain aspects of Western medical practice, including the idea that an apparently healthy person should seek preventive healthcare services.
3.8 Many people who use smokeless tobacco believe that these products can help ease indigestion. Sometimes they are used because people believe it gives them fresh breath or increases their attractiveness. The products may also be taken to ease oral pain, although this can be self-perpetuating, because masking the pain may prolong or exacerbate the underlying problem. Indeed, a former smokeless tobacco user could relapse due to the dental pain they experience when quitting. PHIAC considered that a referral to a medical or dental professional may reduce the likelihood of this happening. For example, they could provide more appropriate pain relief or deal with the actual cause (for example, it may be caused by periodontal disease, pulpitis or caries).
3.9 People may not always be aware that the products they are using contain tobacco. Some may not recognise a general term like 'smokeless tobacco'. (Often they are much more familiar with the names of the individual varieties, such as paan or gutkha.)
3.10 PHIAC was aware of the wide availability of smokeless tobacco from retailers within areas where many South Asian communities live. It was also aware of how relatively cheap these products are compared to cigarettes. However, issues of availability and regulation were outside the scope of this guidance.
3.11 In addition to oral pain (see consideration 3.8), PHIAC noted other possible adverse effects of cessation initiatives. In particular, it noted that giving up smokeless tobacco could lead someone to turn to, or smoke more, cigarettes, or switch to smokeless products that do not contain tobacco but still contain areca nut.
3.12 Practitioners, including doctors, dentists, nurses, midwives and health visitors, are often not well-informed about smokeless tobacco products and the harm they can cause.
3.13 There are few, if any, incentives for health professionals to ask people about, and record information on, smokeless tobacco use. This makes it difficult for local commissioners to gauge the prevalence of the habit locally. It also makes it difficult for them to judge whether or not local tobacco cessation services are proving successful.
3.14 PHIAC noted the lack of high quality randomised controlled trials (RCTs) on tobacco cessation interventions aimed at South Asian communities and involving South Asian varieties of smokeless tobacco. There is also a lack of trials with a relatively long outcome measurement. The standard NHS cessation metric is cessation at 4 weeks, which is a useful standard measure, but too early to be regarded as a proper quit attempt for the purposes of research. Measuring cessation rates at 6 or 12 months might be more appropriate.
3.15 In 2004, UK guidelines on helping people to quit smokeless tobacco were produced (West et al. 2004). Although they do not have any statutory status, the guidelines were endorsed by a number of professional groups and health advocacy organisations. They have an implicit focus on South Asians because they are the main users of smokeless tobacco in the UK. The recommendations were based on high-quality controlled studies mainly related to non-South Asian populations who were using non-South Asian forms of smokeless tobacco. The cessation studies mainly involved the use of nicotine replacement therapy (NRT) and counselling. West et al. (2004) appeared to assume that it was reasonable to transfer these findings to South Asian populations, and to the varieties of smokeless tobacco typically used by these populations. Their recommendations were made on this basis (although, ultimately, they concluded that there was a lack of evidence for NRT). PHIAC discussed the transferability of this evidence. It concluded that, in some cases, the interventions may be effective with other smokeless tobacco users, in other contexts. However, it also noted that the evidence of effectiveness was generally weak. PHIAC took these considerations into account and was also mindful of the general principles of behaviour change (see consideration 3.4).
3.16 PHIAC considered the evidence for treatment using pharmacotherapy and, in particular, the use of NRT. The Committee noted that the Cochrane review evidence (Ebbert et al. 2011) on the use of NRT for smokeless tobacco cessation is equivocal. It also noted that this evidence:
relates to a different type of smokeless tobacco – and populations other than South Asians living in England
only studied the effect of one NRT product at a time (when in practice, someone trying to quit may be using more than one)
covered non-UK study participants who were often unable to make use of the additional behavioural support that is commonly available in England.
Although there is some evidence to suggest that NRT can help South Asian users of smokeless tobacco in England to quit (Croucher et al. 2003), this comes from non-randomised trials with limited follow-up. PHIAC was also aware that NRT is not licensed as a treatment for smokeless tobacco use, although it is on general sale. It also noted that clinicians can use their judgement to prescribe or recommend it.
3.17 PHIAC considered that there might be a particular role for NRT in helping people who smoke and use smokeless tobacco.
3.18 PHIAC noted that research explicitly focused on South Asian users provided an insight into the cultural reasons why South Asians may use smokeless tobacco.
3.19 PHIAC noted that brief advice and tailored, targeted services are a highly cost effective way of helping people to quit smoking. See NICE guidance on brief interventions and referral for smoking cessation; workplace interventions to promote smoking cessation; smoking cessation services and identifying and supporting people most at risk of dying prematurely.
3.20 A threshold analysis estimated that the maximum cost per quitter for a smokeless tobacco intervention to be 'cost effective' depended on someone's age and gender. For someone aged between 20 and 70 years, the cost per quitter ranged from £1758 to £3525 for males, and from £1328 to £2520 for females (when the quality-adjusted life year [QALY] threshold was set at £20,000). At a QALY threshold of £30,000, the cost ranged from £2408 to £4991 for males and from £1795 to £3549 for females.
3.21 The threshold analysis estimates (see above) need to be treated with caution due to the severe data limitations:
lack of evidence on effectiveness
lack of data on the incidence and mortality associated with the smokeless tobacco products used in England, in particular, by South Asians
uncertainty about the time lag between quitting and gaining health benefits – and the extent to which the damage from smokeless tobacco is irreversible.