Smokeless tobacco cessation: South Asian communities

Short Text

Tobacco: helping people of South Asian origin to stop using smokeless tobacco.

Introduction

This pathway covers interventions to help people of South Asian origin who are living in England to stop using smokeless tobacco products.
The phrase 'of South Asian origin' is used in this pathway to mean people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka.
People of South Asian origin are the focus, as they are the predominant users of smokeless tobacco products in England. 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.
Some of the interventions 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.
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.
They should be implemented as part of other activities and services to address the general health needs of South Asian communities.
The pathway is for tobacco cessation services (including stop smoking services), health education and training services, health and wellbeing boards and health and social care practitioners. It is also for all those with public health as part of their remit, in particular, the health of South Asian communities.
It may also be of interest to local authority elected members, people who want to stop using smokeless tobacco, their families and other members of the public.

Source guidance

The NICE guidance that was used to create the pathway.
Smokeless tobacco cessation: South Asian communities. NICE public health guidance 39 (2012)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Updates to this pathway

11 March 2014 Minor maintenance updates.
24 January 2014 Minor maintenance updates.
31 May 2013 Minor maintenance updates.

Supporting information

Smokeless tobacco

The term 'smokeless tobacco' is used in this pathway to refer to any type of product containing tobacco that is placed in the mouth or nose and not burned. It does not include products that are sucked, like 'snus', or similar oral snuff productsAs 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 chewedSee the Local Government Association's Niche Tobacco Products Directory website for further information. .)
The pathway 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 three main categories, based on their ingredients (see the BMJ research paper Global surveillance of oral tobacco products: total nicotine, unionised nicotine and tobacco-specific N-nitrosamines):
  • 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 warningSmokeless 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.). 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.)

Glossary

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's smoking pathway for more information on the general principles of tobacco cessation.
In this pathway, the term 'South Asian' means people with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka.
In this pathway, 'Specialist tobacco cessation service' 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 evidence-based stop smoking services and quitlines in NICE's smoking pathway.
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 evidence-based stop smoking services and quitlines in NICE's smoking pathway.

Assessing local need for smokeless tobacco services

View the 'Assessing local need for smokeless tobacco services' path

Working with South Asian communities

Working with South Asian communities

Recommendations on working with South Asian communities

The recommendations on planning and implementing services and raising awareness of the issues and the services available are for:
  • 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.

Planning and implementing services

Planning and implementing services

Planning and implementing services

Work with local South Asian communities to plan, design, coordinate and implement 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 the NICE pathway 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.
Use venues and events that members of local South Asian communities frequent to provide or consult on cessation services with them. (Examples include educational establishments and premises where prayer groups or cultural events are held.)

Source guidance

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Raising awareness of the issues and the services available

Raising awareness of the issues and the services available

Raising awareness of the issues and the services available

Work with local South Asian communities to publicise activities to help them stop using smokeless tobacco.
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 use consistent terminology in this pathway)
  • 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 cessation services. (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.

Source guidance

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Commissioning smokeless tobacco services

View the 'Commissioning smokeless tobacco services' path

Providing brief advice and referral for further support

Providing brief advice and referral for further support

Providing brief advice and referral for further support

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 be taken?

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 evidence-based stop smoking services and quitlines in NICE's smoking pathway). 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).

Source guidance

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Providing specialist tobacco cessation services

Providing specialist tobacco cessation services

Providing specialist tobacco cessation services

Providers of tobacco cessation services (this may include those working in general practice, dental practices and pharmacies) should, 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 use consistent terminology in this pathway).
  • 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's smoking pathway for more information.

Source guidance

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Training for practitioners in areas of identified need

Training for practitioners in areas of identified need

Training for practitioners in areas of identified need

Commissioners of health and dental services and health education and training services should 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 use consistent terminology in this pathway).
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.

Source guidance

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Paths in this pathway

Pathway created: September 2012 Last updated: March 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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