Shared learning database

Bolton Council, Public Health Team/Bolton CVS Engagement Team
Published date:
April 2013

The Open Wide project is delivered within community settings and aims to raise awareness within Asian communities of the risks of using chewed tobacco and other forms of tobacco such as shisha pipes. The project's group work sessions also highlight the signs and symptoms of oral cancer.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Many people from South Asian populations who chew tobacco or use other forms of oral tobacco and smoke shisha may not recognise their own use, but instead may view themselves as a user of Betel nut, or other associated products. These products are often prepared with or mixed with tobacco for oral consumption. There are also many cultural myths about these products. People believe them to be safe to use and do not recognise the harmful effects on their health.
The Open Wide project aim was to engage people from south Asian communities in interactive health education sessions to:
- Raise awareness of their use of tobacco (through it being mixed with Betel nut, etc)
- Counter myths about the use of chewed tobacco, shisha and other forms of tobacco use, for example that the addition of fruit flavourings does not add any nutritional value to the product.
- Increase participant's knowledge regarding the risks of using chewed and other forms of oral tobacco and shisha pipes, and the links with mouth cancer.
- Increase participants' skills and abilities to resist peer pressure to use oral tobacco and shisha.
- Enable participants to make informed choices regarding their use of oral tobacco and shisha.
- Raise awareness of the signs and symptoms of mouth cancer.

Tobacco cessation information and referral details are provided for each participant at the end of each session.

Participants are also encouraged to sign up to the local Smokefree Homes initiative.

Reasons for implementing your project

The Open Wide project was initiated via the local NHS public health team who were reviewing their tobacco control strategy and were anecdotally getting lots of feedback about an increased use of shisha pipes. This was at the same time as an increase in shisha pipe smoking cafes within Bolton itself and it was felt that something needed to be done to raise awareness of the dangers of using these pipes as research has shown that most young people think that they are harmless and only contain fruit.

There was no baseline prevalence available for Bolton for either use of chewing tobacco or shisha pipe smoking and no national data available but we felt that though there is a lack of data available to establish a baseline, we couldn't let this stop us from carrying out this piece of work because this data may never be available.

The work has also been developed in conjunction with the local authority trading standards team and environmental health teams who are tackling the shisha cafes from an enforcement point of view but are keen to also raise awareness of the health dangers.

How did you implement the project

The initial project proposal stemmed from NHS Bolton feeling that something had to be done to tackle the growing issue in the Asian communities of Bolton and the best way to do this would be through using The Bolton CVS engagement team who are experts in engaging with the community on health issues. The team includes community engagement workers who are able to speak a range of languages and therefore overcome barriers where English is a second language. The team know the local area well and have built good relationships of trust within the community. The project is part of a wider tobacco control strategy 'Tackling tobacco together' , which aims to reduce smoking prevalence in Bolton. However, with Bolton having a higher than average Asian population, Asian tobacco use cannot be something than can be ignored in any wider strategy.

Workshops are provided within community settings, within organisations and settings widely used by people from south Asian communities. Examples of settings include community centres, faith centres as well as local schools.

The project utilises community language skills from within the team, and this has been a key factor in ensuring successful delivery.

The workshops delivered are highly interactive and incorporate and reflect cultural references in relation to the use of tobacco, as well as community names that are frequently used for the products consumed.

Examples of the sessions delivered include:
- Myth buster (truth game)
- Newspaper headlines
- Shisha journey: which incorporates a mapping exercise revealing historical and cultural facts regarding shisha as well as highlighting the risks associated with its use.
- Role play: to help equip participants with the skills to resist family or peer pressure to use oral tobacco. This is a key tool in the delivery for young people and within schools settings.
-'Hubble Bubble Shisha Trouble' - adapted from the chemical soup kit developed by Barnardos - this is a visual means of explaining the different chemicals that go into the shisha.
-Paan Leaf Display - a large paan leaf with the different actual ingredients on display enables participants to relate to what goes in the pan and their harmful effects.
-A healthy and unhealthy mouth game ? an opportunity for participants to pick the items that make a healthy mouth and an unhealthy mouth.

Key findings

The project has received positive feedback from participants, including from parents and older members of the community who may have not initially recognised their own use of oral tobacco. The Open Wide project has gathered some case studies of people who have since given up or reduced oral tobacco/shisha smoking after taking part in their project sessions. 1,763 people have taken part in the project, with 570 of these being during 2012-13. In addition, 422 people have been given brief advice.

734 people have also been encouraged to sign up to the local Smokefree Homes.

Key learning points

We have learnt that it is important to adapt the tools used according to the age group. Using hands on and interactive games and tools have the most impact and people remember this after the workshop.

It is difficult to assess outcomes as encouraging people to make behaviour changes is a long term process and often we are not able to track people over a period of time.

It is difficult to challenge behaviours which have been part of a cultural for many years and people will sometimes find this difficult to accept.

The lack of consistent long term research about the health impact of shisha can lead to questioning of your intervention and to changes to information needing to be made based on new findings. Avoid making wild claims before checking the source of the research and its validity.

Contact details

Liz Wigg/Louise McDade
Health Improvement Specialist
Bolton Council, Public Health Team/Bolton CVS Engagement Team

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