Behaviour change intervention for smokeless tobacco cessation: its development, feasibility and fidelity testing in Pakistan and in the UK

Abstract

BackgroundPeople of South Asian-origin are responsible for more than three-quarters of all the smokeless tobacco (SLT) consumption worldwide; yet there is little evidence on the effect of SLT cessation interventions in this population. South Asians use highly addictive and hazardous SLT products that have a strong socio-cultural dimension. We designed a bespoke behaviour change intervention (BCI) to support South Asians in quitting SLT and then evaluated its feasibility in Pakistan and in the UK.MethodsWe conducted two literature reviews to identify determinants of SLT use among South Asians and behaviour change techniques (BCTs) likely to modify these, respectively. Iterative consensus development workshops helped in selecting potent BCTs for BCI and designing activities and materials to deliver these. We piloted the BCI in 32 SLT users. All BCI sessions were audiotaped and analysed for adherence to intervention content and the quality of interaction (fidelity index). In-depth interviews with16 participants and five advisors assessed acceptability and feasibility of delivering the BCI, respectively. Quit success was assessed at 6 months by saliva/urine cotinine.ResultsThe BCI included 23 activities and an interactive pictorial resource that supported these. Activities included raising awareness of the harms of SLT use and benefits of quitting, boosting clients’ motivation and self-efficacy, and developing strategies to manage their triggers, withdrawal symptoms, and relapse should that occur. Betel quid and Guthka were the common forms of SLT used. Pakistani clients were more SLT dependent than those in the UK. Out of 32, four participants had undetectable cotinine at 6 months. Fidelity scores for each site varied between 11.2 and 42.6 for adherence to content – maximum score achievable 44; and between 1.4 and 14 for the quality of interaction - maximum score achievable was 14. Interviews with advisors highlighted the need for additional training on BCTs, integrating nicotine replacement and reducing duration of the pre-quit session. Clients were receptive to health messages but most reported SLT reduction rather than complete cessation.ConclusionWe developed a theory-based BCI that was also acceptable and feasible to deliver with moderate fidelity scores. It now needs to be evaluated in an effectiveness trial.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3177-8) contains supplementary material, which is available to authorized users.

Smokeless tobacco consumption among public and heavy load drivers in Karachi, Pakistan: A cross-sectional study

“…In a recent survey of SLT consumers in Bangladesh and Pakistan (Azam et al, 2016;Siddiqi et al, 2016), the respondents indicated that their decisions to begin SLT use were influenced by peer pressure, family acceptance, easy access, low price, lack of regulation, wide cultural acceptance, curiosity, and hospitality. Among drivers in our study with a low SES who were unable to afford chewing gum, SLT served as a cost-effective, albeit addictive and alternative option for maintaining alertness during long duty hours.…”

“…However, they resumed use after experiencing strong withdrawal symptoms and because of a perceived occupational dependence on SLT. A similar study of factors related to behavioral interventions aimed at SLT cessation in Pakistan and the UK reported that 33 to 63% of SLT consumers were attempting to cease use of these addictive products but were unsuccessful because of peer pressure, isolation, and inconsistent motivation (Siddiqi et al, 2016). Similarly, as evident (Table 4 and 5) SLT consumption is 3-fold related to extra-long duty hours (>16), which alone is significant in univariate analysis; whereas in the presence of reduced (or No) influence by family or community environment, it might no longer remain significant as seen in multivariable analysis.…”

“…Although more than 300 million adults in at least 115 countries consume smokeless tobacco (SLT), these products are used with particular frequency in both South and Southeast Asia. For example, SLT is used regularly by a quarter of adults in Bangladesh and India and by 16.3 and 2.4% of male and female Pakistani residents, respectively (Siddiqi et al, 2016).…”

A Policy Perspective on the Global Use of Smokeless Tobacco

“…Most ST products contain a high nicotine concentration [ 4 ] and regular users show strong dependency [ 59 , 60 ]. Compared to smoking cessation, the evidence for ST cessation is limited and complicated by ST heterogeneity [ 61 ]. A Cochrane review [ 62 ], while concluding that pharmacotherapies and behavioural support may help ST users to quit, did not include any South Asian studies.…”

“…The latter findings were replicated in a multi-centre cohort study across South Asia [ 65 ]. A feasibility study found a culturally appropriate behaviour change intervention was acceptable to ST users in Pakistan and the UK [ 61 ]. One Indian RCT observed no difference in quit rates at 12 weeks (varenicline vs. placebo) [ 66 ], and a second showed a small effect of a community outreach intervention on abstinence at 6 months [ 67 ].…”