Adapting a behavioural support intervention for smokeless tobacco cessation in South Asians

Smokeless tobacco is a product containing tobacco, placed in the mouth or nose but not burned at the time of use. Consumed by approximately 300 million people worldwide, smokeless tobacco use leads to heart disease, stroke, and cancer of the mouth, oesophagus and pancreas. Its use is particularly common and considered socially acceptable among people of South Asian-origin including those living in the UK. According to latest research, behavioural counselling helps people addicted to smokeless tobacco in quitting. However, this research, mainly conducted in the US and European populations, is of little relevance to South Asians who use more addictive and hazardous products. Moreover, smokeless tobacco use among South Asians has strong socio-cultural dimensions, which need to be considered in behavioural counselling. Counsellors in the UK commonly modify their advice when offering behavioural counselling to smokeless tobacco users of South Asian-origin. However, there are variations in practice, and no standard protocol or any evidence for the effectiveness of an adapted approach.
We aim to identify the modification required in behavioural counselling to make it more effective, feasible and acceptable to South Asians in supporting them to quit smokeless tobacco. We will first get a group of experts to propose required modifications in the counselling sessions. We will then offer these to smokeless tobacco users in two health facilities in the UK and in Pakistan respectively.

Around 300 million people worldwide consume smokeless tobacco. Considered to be a part of the culture, its use is particularly common in people of South Asian-origin1. A quarter of adults in India and Bangladesh and a fifth in Pakistan use smokeless tobacco. Also popular in the South Asian diaspora; one in five Bangladeshi women in the UK is a regular user. In addition to cardiovascular diseases, smokeless tobacco use leads to oral, oesophageal, and pancreatic cancers.
A recent Cochrane review suggests that behavioural support interventions are likely to be effective in smokeless tobacco cessation. However, studies in this review were mainly conducted in the US and European populations who, compared to South Asians, use less addictive and less hazardous products (e.g. moist snuff). Moreover, its consumption among South Asians has strong socio-cultural dimensions, which need to be considered in behavioural support interventions. The cessation advisors in the UK, offering behavioural support to smokeless tobacco users of South Asian-origin commonly modify their advice according to what they perceive appropriate. However, there are variations in practice, no standard treatment protocol for a culturally adapted intervention and no evidence for its effectiveness.
We aim to identify the modifications required to a behavioural support intervention in order to make it more effective, feasible, and acceptable for South Asians in smokeless tobacco cessation. We will adapt, test and refine the intervention in three phases. An expert panel will agree on the required adaptations. We will then assess the feasibility, adherence and acceptability of the adapted intervention. The intervention will be delivered by four cessation advisors to 32 participants (smokeless tobacco users) at two different sites (UK and Pakistan). We will audiotape and analyse 96 behavioural support sessions, interview 16 participants and four advisors to assess feasibility, adherence and acceptability. Findings will inform any further modifications.