Smokeless tobacco

Chewing tobacco (a form of smokeless tobacco) can be harmful to health. It is known to lead to oral and oesophageal cancers, as well as disabling sub-mucosal fibrosis.  For years, in the absence of clear guidance, some users have been treated by local stop smoking services, on the grounds that individuals seeking help for tobacco use of any kind should be offered support within the NHS.

There seems a moral case to act on behalf of a section of the population who, already marginalised, are seeking help (albeit in small numbers) for health harming behaviours that are deeply embedded in their culture.

However, since April 2009 Department of Health guidance has made it clear that users of smokeless tobacco are not to be counted for monitoring purposes by the stop smoking services. 

This article argues that in areas of the UK with high numbers of residents who are South Asian, services should be commissioned to treat those addicted to chewing tobacco. This argument is based on an acceptance that chewing tobacco is an addiction that warrants treatment paid for by the NHS, in exactly the same way as smoking. 

Can the commissioning cycle be used to help break the habit? 

The structured approach of world class commissioning has the potential to help develop services that are responsive to the needs of different forms of tobacco users, in a bid to reduce inequalities within the population. The three key elements of the WCC cycle are strategic planning, procuring services, and monitoring and evaluating.

Strategic planning of services

This includes health needs assessment, review of service provision and prioritisation. 

The joint strategic needs assessment provides evidence of the demography of the local population. Clarity regarding ethnicity is crucial in understanding whether chewing tobacco use may be a specific concern within the local population.

Census data can be used to identify relevant ethnic groups at local authority district level and neighbourhood statistics at more localised levels. 

Looking at this data by count (to see where there are large numbers of residents from South Asian communities) and also as a proportion is useful, as in some areas there are large South Asian communities that represent only a small proportion of the population in that area.

In terms of current access to services, the NHS Information Centre’s statistics on stop smoking services show that the proportion of the South Asian community currently accessing services tends to be less than the proportion of the population that is South Asian. This is in the context of smoking prevalence, which among Bangladeshi men is 42 per cent, Indian men 21 per cent and Pakistani men 24 per cent. Nationally, prevalence information is available from the Health Survey for England’s 1999 and 2004 surveys, which are planned to be repeated in a year.

Chewing tobacco use (and the types of products used) is not uniform across all South Asian groups.  Assessing health needs therefore should include dialogue with community members themselves, to ensure a better understanding of the cultural and social place of chewing tobacco products, including level of awareness of health effects and willingness to quit. 

Research reports that 67 per cent of Bangladeshi women declare a desire to quit using chewing tobacco products. Such assessment can be aided by accessing local knowledge among community based services, projects, local surveys, community development workers and information from the stop smoking service.

Procuring services

Procuring services includes service design, shaping the structure of supply, planning capacity and managing demand.

So, from where should these services be procured? There are some examples of successful, long established services for chewing tobacco users such as the Bangladeshi stop tobacco project in Tower Hamlets. This service has a detailed and culturally sensitive understanding of chewing tobacco use in its population, actively promotes its services, offers training to all providing the service at a wide variety of community based settings and uses a wide variety of models of service delivery that offer considerable client choice. 

However, the size of the South Asian population in other areas may not warrant similar dedicated services.

It is arguable that current stop smoking services may not be the only vehicle for delivery – their record in reaching black and minority ethnic communities is mixed and they are clearly focused on supporting people to quit smoking.

Evidence indicates that oral examination coupled with advice delivered in dental surgeries may provide an alternative route, although there may be a difference in frequency of dental visits among users and non-users of tobacco.

Therefore, a mixed mode of delivery including stimulating the market by exploring service delivery through local community-based providers may be necessary.

Procuring services should be based on a clear service specification. This highlights the need for a robust evidence-based protocol (such as the weekly specialist advice programme commonly used within NHS stop smoking services) to support chewing tobacco users.  No such protocol currently exists and the evidence base is weak. Little research has been carried out on treatment for the types of chewing tobacco used in the UK.

It seems clear that planning capacity and demand requires an understanding of the cultural differences among populations of users; a sensitive and culturally competent workforce will open doors to dialogue just as a well-intentioned but ultimately clumsy approach will close them.

In light of the absence of an evidence based protocol, this dialogue should include exploring different models of support with chewing tobacco users to establish which might be appropriate and feasible.

Monitoring and evaluating

This includes performance management and seeking the views of patients and the public.

The final part of the cycle relates to monitoring and evaluation, reflecting closely the detail of the service specification. A structure, process, output and outcome evaluation framework can be a useful starting point for assessing quality of service provision for this part of the WCC approach.

Current performance management and targets for smokers who quit are set within the PCT’s vital signs targets monitored on a quarterly basis. However, verification of people who quit chewing tobacco is problematic. Self-reporting is potentially the main measure as verification via expired air carbon monoxide is inappropriate and saliva cotinine is a costly option that wouldn’t be appropriate if quitters were using nicotine replacement therapies.

However, the importance of targets as a tool for raising the profile of key health priorities should not be underestimated and indeed the primary monitoring of the NHS stop smoking services is through self-reporting, so this may offer a good starting point.

Finally, the evaluation of services informs the next stage of the needs assessment for future service development and this should involve user feedback.

To conclude, there are some clear questions that primary care trusts need to ask themselves, not least of which is ‘do we know where our South Asian populations live and if so are we providing a service for chewing tobacco users?’

As with many aspects of health, when public services set out to tailor interventions for minority ethnic groups, there is a need to start with the question: What do these communities want? How else are we to understand the cultural and social place of these products, known to cause serious harm but central to the daily lives of thousands of people? And would a very public offer of treatment for the use of chewing tobacco raise awareness of the stop smoking services too?

It seems clear that no straightforward answers will present themselves without close collaboration between the commissioners, the providers, community workers, and the communities themselves.

This article is based on research funded by Cancer Research UK